Narcissistic personality disorder (NPD) is marked by a pattern of grandiose thinking and behavior, a persistent need for admiration, and a lack of empathy for others. Individuals with NPD can appear highly functional, especially at their chosen occupations, and can be sociable and charismatic. However, people with NPD have long-standing issues with profound insecurities and fears of rejection.
Please note that the terms narcissism and narcissistic can be misused. In this article, the terms are used to describe aspects of narcissistic personality disorder.
What Are Personality Disorders?
A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture; is pervasive and inflexible; has an onset in adolescence or early adulthood; is stable over time; and leads to distress or impairment in interpersonal, social, and occupational functioning. Personality disorders not only create severe consequences in the lives of people who have the condition but can damage the lives of people around them.
When discussing psychological disorders and their treatments, there is typically a need to separate clinical disorders from personality disorders. While this attempt at creating a distinction may be confusing at times, it can be useful to view certain disorders as the result of biological or environmental factors that are separate from the person’s actual character, and those which more reflect a person’s core beliefs in themselves and others.
Diagnosis of Narcissistic Personality Disorder
NPD involves a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts.
To be diagnosed with NPD, an individual must present with five or more of the following:1
- Have a grandiose sense of self-importance
- Exaggerate achievements and talents
- Have a sense of entitlement and require constant adulation
- Expect to be recognized as superior even without achievements that warrant it
- Be preoccupied with fantasies about success, power, brilliance, beauty, or the perfect mate
- Believe they are superior and can associate only with equally special people or institutions
- Monopolize conversations and belittle or look down on people whom they perceive as inferior
- Expect special favors and unquestioning compliance
- Take advantage of others to get what they want
- Have an inability or unwillingness to recognize the needs and feelings of others
- Be envious of others and believe others envy them
- Behave in an arrogant or haughty manner, coming across as conceited, boastful, and pretentious
- Insist on having the best of everything — for instance, the best car or office
At the same time, people with narcissistic personality disorder have trouble handling anything they perceive as criticism, and they can:2
- Become impatient or angry when they don’t receive special treatment
- Have major interpersonal problems and easily feel slighted
- React with rage or contempt and try to belittle the other person to make themselves appear superior
- Have difficulty regulating emotions and behavior
- Experience major problems dealing with stress and adapting to change
- Feel depressed and moody because they fall short of perfection
- Have secret feelings of insecurity, shame, vulnerability and humiliation
7 Signs of Narcissistic Personality Disorder
Signs and symptoms of narcissistic personality disorder and the severity of symptoms vary, but signs of NPD include entitlement, grandiose thinking, and insecurity.
Here are 7 signs that may indicate narcissistic personality disorder:
1. Entitlement
In NPD, a person feels entitlement, which is defined as an exaggerated sense of importance compared with others around them, and as a result, they will often believe they should be treated differently in relationships and in the surrounding society.
2. Grandiose Thinking
Grandiose thinking in those with NPD can be so extreme that they believe their achievements and talents greatly exceed what they actually accomplished. People with NPD routinely do not accept actual failures or obvious shortcomings, even those that most people would accept as typical in life. When confronted with such failures or shortcomings, the person with NPD will frequently push back with excuses or gaslighting, which is a form of psychological manipulation that involves making another person question their mental health.
3. Insecurity
Because NPD is the result of profound insecurities in the self, the individual with the disorder requires excessive admiration from others. In fact, this need can be so insatiable, that it can singularly drive the person with NPD to ignore or abuse relationships or responsibilities simply to gain greater forms of attention. Any sense of duty to committed relationships, including marriage and family, or to higher values (e.g., an organizational mission, service to country, religious tenets) would be easily disregarded in favor of self-enrichment.
Consequently, many people with NPD can be very controlling and abusive in personal relationships as well as in leadership roles. They often resort to sexual acting-out and extramarital affairs, emotional coldness towards partners, avoidance of interpersonal responsibility, or humiliation tactics. In the workplace, they can abuse their authority by demanding loyalty over achievement and creating hostile work environments, especially against those who are under their supervision or anyone whom they believe can undermine their control.
In the worst form of NPD, others are simply objects of the individual’s personal need to get whatever they want. Those with severe NPD expect others to serve them and, in a sense, pledge to them their loyalty. If others do not conform to these demands, they can be treated with hostility and utter disregard.
4. Deception
It may seem simple that others could easily see through the selfish and abusive aspects of NPD, and thus avoid anyone with those traits. However, a person with NPD can be quite deceiving, at least at first. Many people with NPD can present socially as charismatic, exceptional, personable, or even helpful. They can be artful at creating a cult-like persona that some may find as attractive or as someone who can meet their own deeper psychological needs.
It is likely true that someone with NPD has such profound insecurities that they are often able to speak to the insecurities of others in such a way that they connect psychologically. In other words, those who feel frightened, resentful, or defeated by life may witness in the narcissistic person a savior from their desperation, and easily become enamored by this form of charisma. But when it comes to NPD, these misguided sentiments will prove deceptive and potentially destructive.
If someone with NPD is confronted by larger forces or circumstances, they can lash out and even become destructive to the people and institutions around them—essentially anyone or anything that they believe has proven disloyal.
5. Bullying
Those with NPD often engage in bullying tactics. These behaviors can frequently be traced to childhood when narcissistic people were bullies who felt insecure, entitled, and justified in their abusive behavior. But while some childhood bullies may overcome their fears and aggressions as they approach adulthood, people with NPD typically do not.
People with NPD may bully others in their ongoing quest to both solidify power and position in adult life, while promoting their self-image by reducing the prestige of anyone around them. Instead of elevating one’s position by legitimate achievement, those with narcissism seek to belittle others to appear superior.
People with NPD tend to ignore facts and the opinions of experts around them to accomplish their goals. They often feel threatened when confronted by realities that challenge their grandiose fantasies, not only because they must contend with being wrong on a subject but also because they envy those regarded as legitimately superior in their knowledge and skills. As a result, people with NPD often feel menaced by opposing truths. Thus, instead of incorporating truths into a workable solution to problems, they instead regard the messengers of facts and contradictory opinions as threats that require expulsion. This behavior can play out in personal relationships, workplace environments, and in leadership roles.
6. Emotional Instability
Emotional instability is an important aspect of NPD. Narcissism allows for the expression of any feeling that the individual believes is necessary to maintain control of any interpersonal situation. Therefore, people with NPD can appear pleasant, interested, or helpful in one situation and rageful or aggressive in another.
7. Relationship Issues
Sometimes a person in a relationship with someone who is narcissistic can be made to believe that they must be the problem if the person with NPD gets angry at them. The object of that rage may say, “I must have done something wrong. He’s normally a nice person.” People in relationships with those who have NPD will not only blame themselves for the actions of those with NPD but can come to feel trapped in that relationship.
The rapid changes in mood and behavior with NPD can create confusion, shame, and self-doubt in people who are in those relationships, and they can actually fear any attempt to confront or leave the person with NPD.
Narcissistic Defense Mechanisms
With or without a co-occurring substance use disorder, denial is a common defense mechanism in NPD. There are also other defenses typical for NPD also, including projection and distortion.
Projection
Projection is a defense used by narcissistic people to essentially take what is wrong, bad, or deeply insecure about themselves and focus it onto another person or group of people. This deflection keeps the bad things about the person with NPD away from their awareness and sense of responsibility, and lowers the other person down to a demeaning and controllable level.
An example is a supervisor who has a long history of insecurity over her poor academic and occupational performance. Instead of working harder to improve herself, she frequently puts others down, calling them mocking names, while increasing their work assignments beyond reason, so her employees will eventually fail.
Another example of projection involves the person with NPD making accusations against others that more likely reflects what the person with NPD is doing. This projection may take the form of a husband intent on hiding his extramarital affairs by saying to his wife, “I know you’re cheating on me!”
Distortion
Similar to projection, distortion is a narcissistic defense that seeks to confuse facts and reality to protect the narcissistic self. People with NPD will often attempt to convince others—especially romantic partners—that what they are witnessing in the person’s narcissistic behavior is not actually happening.
This type of manipulation is sometimes referred to as gaslighting, and is particularly dangerous to the object of the distortion. Family members who are constantly exposed to narcissistic distortions can suffer a host of psychological consequences, and feel trapped in their relationships.
Distortion is often employed by people with NPD in leadership positions to create cult-like followers who are psychologically manipulated to believe that their leader is the only person who knows the “real truth” of the world around them.
Co-Occurring Mental Health Problems
Other mental health problems can co-occur with NPD. More than 40% of people with NPD have a substance use disorder. About 30% also have a co-occurring mood disorder, and an approximately one third struggle with anxiety.3
When mood disorders co-occur with NPD, symptoms generally present as the individual experiences a major setback that narcissistic behaviors alone cannot rectify, also referred to as a “narcissistic injury.” The injury is the perceived damage to the person’s ego, or sense of self, and the injured person may become angry and hostile but also sad and anxious that the world has defied them.
Substance use disorders are common in people with NPD—most notably, alcohol, cannabis, and stimulants such as cocaine and amphetamines. Generally, people with NPD and a co-occurring substance use disorder are seeking or intensifying a sense of power, either socially or internally by maintaining a false sense of strength and their grandiose fantasies, as is particularly the case with stimulant use.
Alcohol can increase aggression, which can make domestic disputes more dangerous. People with NPD can be intensely in denial about their drug and alcohol use. They often deflect blame to protect their habits. A narcissistic person may say, “I’m not the one with the problem. You’re the one with the problem!”
Treatment for Narcissistic Personality Disorder
A thorough scientific exploration of the effectiveness of NPD treatments, especially with medications and various talk-based therapies, has yet to be performed.4 But it is generally believed that long-term psychotherapy offers the best and most viable opportunity for those with NPD who seek treatment.
Therapy
Psychotherapy is essential in treating the long-standing underlying issues of emotional insecurity, interpersonal dysfunction, and the various life consequences as a direct result of NPD. Different modes of therapy include individual, couples, family, and group therapy. However, since people with NPD often attempt to act out their need to control and dominate relationships, it is often preferred to initiate therapy for NPD in the individual setting, or at least, have individual therapy alongside other necessary therapeutic activities.
Medication
Psychiatric medications can be helpful in cases where individuals experience symptoms related to anxiety, mood disorders, certain addictions, or any other co-occurring psychological disorders.
Challenges in Getting Treatment
Not all people with NPD willingly participate in treatment for the disorder. Though some may eventually come to realize that narcissism is not working for them in their everyday lives, many begin therapy under some pressure to do so. This pressure may be the result of a relationship separation or pending divorce, an out-of-control substance use problem, or legal troubles. The therapist may be initially viewed by the person with NPD as a way out of their immediate conflicts.
One of the biggest challenges in therapy for NPD involves trust. Developing trust and rapport with a therapist is of cardinal importance in NPD treatment. People with this type of personality disorder frequently feel challenged and somewhat fearful of the therapist, especially if they get the sense immediately that the therapist cannot be easily controlled by their own interpersonal style.
When choosing a therapist, it’s important to understand their experience in managing narcissism in therapy, and understanding the challenges of this personality disorder.
Psychotherapists with proper experience or supervision in treating NPD often recognize the delicate balance between offering the patient needed support for feeling misunderstood and victimized on the one hand, and working towards authentic self-image and improved relationships on the other. It often takes time to form the trust needed to gradually confront denial and help the person with NPD to humbly accept their genuine humanity. Along the way, people with NPD can easily get frustrated with the therapy process for any number of reasons, including the exposure of feelings of vulnerability or inferiority in the presence of the therapist.
As trust develops, therapy for NPD can eventually delve into early-life conflicts which may have largely contributed to the narcissistic patterns in adulthood. A trusted therapist with experience in NPD treatment can adjust the level of intensity and challenge to the therapy patient to maintain progress. Commonly, people with NPD will experience considerable grief over perceived losses involving grandiose self-image, entitlement, exaggerated victim status, and dealing with a humbler outlook.
Predictably, the therapy process can be difficult for people with NPD, especially as the process moves towards a more realistic portrayal of the person’s life. Denial can be a stubborn defense mechanism. As a result, people with NPD will at times discontinue therapy or switch therapists to suit their own narcissistic beliefs.
But if the person with NPD can move past denial and begin to accept their own conflicts and shortcomings, they can adopt more constructive coping methods. In this way, people with NPD can develop a more secure sense of self that accompanies genuine confidence, instead of arrogance and bluster that only covers feelings of inadequacy. From that position, people with NPD generally do better in couples or group therapy, and can better tolerate working together with others on an equal footing.
People who work-through their narcissistic tendencies typically approach relationship counseling, sober living, leadership responsibilities, and parenting challenges more effectively.
Treatment for NPD-Induced Trauma
Psychological treatment may be necessary for people who have suffered in relationships in which narcissism was present. Those who have been subjected to gaslighting, rage, and a deconstruction of their own sense of reality may develop psychological trauma, including post-traumatic stress disorder (PTSD).
They may also experience depression, anxiety, lowered self-esteem, and poor self-reliance. People who are the objects of narcissism over a period of time may feel trapped in the relationship and develop a condition sometimes called Stockholm syndrome.5 This concept refers to someone forming an emotional attachment to someone who is persistently abusive, creating a codependency akin to a dysfunctional parent-child dynamic.
Psychotherapy can help an individual work-through traumatic experiences and reshape their sense of reality. With improved self-esteem, people can make better choices on how to proceed with their relationships and their own feeling of independence.
Often, people who have suffered narcissistic-related trauma may not desire to engage in couple’s therapy until they and their partners with NPD have reached some measure of success in individual therapy. It can be difficult to assess how prepared people with NPD are for the rigors of relationship therapy without having their usual narcissistic defenses in place. Consultation with an experienced therapist can be useful to determine which therapy interventions can be most helpful, and in creating together an ongoing plan to monitor overall treatment success.
