Narcissistic Personality Disorder (NPD): Signs, Symptoms, & Treatments

What Is Narcissistic Personality Disorder (NPD)?

Narcissistic personality disorder (NPD) is marked by a grandiose sense of self and a lack of empathy.³ Unlike other forms of mental illness, narcissism and personality disorders affect a person’s very nature and distort their understanding of themselves. They also affect one’s relationships and friendships, often resulting in a decreased ability to connect and form healthy bonds with others.^4,7

How Common Is NPD?

In community samples, diagnosable cases of NPD range from 0% to 6.2% with an estimation that 50%-75% are men.⁷ Many people may experience NPD or healthy narcissism traits, but possessing the clinical requirements of narcissistic personality disorder is quite rare. These traits typically become obvious in adolescence, although NPD can also be diagnosed in adulthood.

Clinical Narcissism Vs. Narcissistic Traits

People can display traits of narcissism but not have narcissistic personality disorder. For example, narcissistic traits, such as a lack of empathy, entitlement, and an absence of personal insight, do not automatically warrant a diagnosis of NPD.

To receive a diagnosis, a person must meet the DSM 5 clinical criteria for narcissistic personality disorder. Overall, the negative characteristics of NPD must significantly impact one’s functioning in all areas of their life on a consistent basis.

Different Types of Narcissists

While the DSM 5 doesn’t formally recognize NPD subtypes, many experts believe these do exist.^2,3,5,8 Different forms of narcissism can lead people to display various traits, tendencies, symptoms, and behaviors.

Different types of narcissism include:^2,4,5,8

• Overt narcissist: Overt or grandiose narcissism generally fits the stereotype of what most people think of when they hear the term “narcissist.” Grandiose narcissists typically present as being self-important, arrogant, boastful, and extroverted.
• Covert narcissist: The covert narcissist or vulnerable narcissist is harder to spot because they are more quiet, shy, or reserved in nature, especially when they are insecure or upset. They may appear as moody, needy, and brooding types.
• Communal narcissist: Communal narcissism appears selfless, generous, and even humble to others. Communal narcissists dedicate time and energy to like-minded people, community causes, or other high-profile charities. They get their validation by being seen as the most giving and selfless.
• Malignant narcissist: Malignant narcissism is a term used to describe a person who displays traits and tendencies of both NPD and antisocial personality disorder. These individuals are often seen as having one of the most dangerous forms of narcissism.
• Sexual narcissist: A seductive or sexual narcissist uses charm and flowery speech to seduce you. However, they will only prioritize their own sexual needs and completely ignore those of their partner. They seek constant validation regarding their sexual performance and experience.
• Somatic Narcissist: A somatic narcissist is preoccupied with their physical appearance and competitive about how they look. They may obsess over their diet, exercise excessively, and fixate on wellness routines or beauty treatments. A somatic narcissist will use their body (or sex) to get what they want.
• Spiritual Narcissist: A spiritual narcissist uses spirituality to fill their narcissistic supply. They believe that their beliefs are superior and may use scripture to manipulate others.
• Cerebral Narcissist: Cerebral narcissists hyperfixate on how much smarter they are than others. They may use technical and cumbersome terms in normal conversation or discuss complex theories to prove their superior intellect.
• Vindictive Narcissist: A vindictive narcissist is often offended and hurt by boundary-setting from others. They will seek revenge to harm you and “get you back” for rejecting them. When you set a boundary or criticize them, they will find a way to retaliate.

Signs & Traits of Narcissistic Personality Disorder

A person’s narcissistic traits or characteristics will not always be obvious initially. However, there are common signs to look for if you suspect someone is a narcissist. Signs of narcissism include a constant need for validation and praise, a pretentious demeanor, and hypersensitivity to criticism.

Common traits and signs of a narcissist include:^1,3,6,7

• Extreme sensitivity to criticism, rejection, and negative feedback
• Inflated sense of self or confidence
• Inability to take responsibility for actions
• Tendency to make everything about themselves
• Projection of anger and blame onto others
• Using narcissistic manipulation tactics to exploit others
• Lack of healthy relationships
• Holding grudges and seeking revenge
• Frequent devaluing of relationships or discarding people
• Refusal to admit or experience vulnerable emotions
• Being overly jealous, controlling, or possessive of others

Narcissistic Personality Disorder Symptoms

The symptoms of narcissistic personality disorder are standardized according to the DSM 5. However, exhibiting symptoms can differ depending on the individual and the type of narcissism they possess.

According to the DSM 5, narcissistic personality disorder symptoms include:³

• A sense of grandiosity or excessive self-importance
• Recurrent fantasies of being powerful, successful, beautiful, or important
• Beliefs of being special and exceptional
• Excessive need for validation, praise, and admiration from others
• Feeling deserving of special treatment
• Exploiting others for personal gain or selfish reasons
• Lacking empathy or being unwilling to identify with the needs of others
• Being envious of others or believing others are envious of them
• Arrogant or haughty behavior

What Causes Narcissism?

There is inconsistent and inconclusive research regarding the causes of narcissistic personality disorder. However, a combination of genetic, social, familial, and environmental factors is likely the cause of narcissism. Further studies are needed to determine which, if any, of these elements may play a larger role in its development.

A recent study of 304 sets of twins found that some traits associated with NPD, particularly grandiosity and entitlement, may be inherited.⁹ Furthermore, a separate study suggests that narcissism has the highest rate of heritability among cluster B personality disorders.¹⁰

Possible causes of narcissistic personality disorder include:

• Genetic factors: While genetics may play a part in the development of NPD, it’s more likely someone will be predisposed to the disorder if these traits are present.
• Childhood trauma: Childhood trauma creates emotional wounds over time, leading a child to feel devalued or shameful.¹¹ This may explain the low self-esteem characteristic of NPD.
• Inconsistent parenting styles: Inconsistent, overprotective, or neglectful parenting styles may contribute to the onset of narcissistic personality disorder.
• Personality and temperament: Overly independent, outgoing, and charming children may lean more toward narcissism. However, these traits can easily change over time.
• Learning behaviors from others: Children may learn narcissistic tendencies from parents or family members that can influence their self-beliefs, behaviors, and approach to relationships.
• Being excessively praised or criticized: Frequent criticism can lead to shame and self-resentment in children. Conversely, excessive praise can contribute to an inflated sense of self.  Either type of feedback can significantly impact a child’s self-image.
• Being excessively pampered: If children are pampered by caregivers, they may learn to expect this same treatment from others and hold high regard for themselves.

Complications of Narcissistic Personality Disorder

Because narcissists cannot establish an internal sense of worth, they rely on external attention to feel special or important. When do not receive the treatment they believe they deserve, they can experience a narcissistic collapse, become defensive, or even react with narcissistic rage.^4,6 This aggression may worsen if a narcissistic injury occurs and their personal insecurities are exposed.

Narcissistic relationships are often tumultuous and one-sided. People with NPD struggle to connect with others, making it difficult to form healthy, reciprocal, and close relationships. Further, their low self-esteem, defense mechanisms, and lack of empathy tend to push people away from the start.

Complications of living with narcissistic personality disorder may include:⁹

• Poor relationships
• Increased risk for suicidal ideation or actions
• Presence of co-occurring mental health conditions
• Academic or work-related problems
• Substance misuse

How Is Narcissistic Personality Disorder Diagnosed?

Typically, diagnosing NPD will begin with a biopsychosocial assessment by a licensed therapist, psychiatrist, or psychologist. This gathers information about a person regarding their traits, how long characteristics have been present, and the impact these have on their life and overall functioning. The therapist may also use different personality assessment questionnaires to assess the individual’s attributes. An NPD diagnosis is based on these factors and the DSM 5 criteria for narcissistic personality disorder.

Are There Tests for NPD?

There are many assessment tools that clinicians may utilize to help pinpoint a diagnosis of NPD. While some of these tests are available to the public, the only way to confirm a diagnosis is to schedule a formal assessment with a properly licensed professional.

Common tests used to identify narcissistic personality disorder include:

• Personality Diagnostic Questionnaire-4 (PDQ-4): PDQ-4 is a 99-item self-report used to identify the diagnostic criteria for NPD from the DSM5.
• Millon clinical multiaxial inventory III (MCMI-III): The MCMI-III is a self-provided report of personality characteristics used to assess for clinical NPD symptoms within those traits.
• International personality disorder examination (IPDE): An IPDE test is comprised of six sections and uses open-ended questions. It is used to assess each area of a person’s life affected by narcissism.
• The Pathological Narcissism Inventory (PNI): The PNI is a 52-item self-report measure that evaluates seven areas of pathological narcissism including rage, grandiosity, and vulnerability.
• The Brief Pathological Narcissism Inventory (B-PNI): This test is a shorter version of the PNI. However, it was created using 28 original PNI measures.
• The Narcissistic Personality Inventory (NPI): The NPI is a shorter assessment used to understand subclinical symptoms and is not considered the sole diagnostic tool.

Narcissistic Personality Disorder Treatments

Treatments for narcissistic personality disorder typically include psychotherapy, sometimes in combination with medications for co-occurring mental health conditions. Unfortunately, rarely do narcissists seek treatment for their behavior.^1,4,7 Narcissists who do seek therapy may do so only after being coerced or when seeking help for an underlying issue or problem.

Still, narcissists who sincerely want and are willing to receive help can improve their behavior. The first step in the process is finding a therapist who is compassionate, knowledgeable, and experienced in treating narcissism.^1,4

Therapy for Narcissism

While there aren’t specific therapies for narcissistic personality disorder, many types can be beneficial.⁴ Dropout rates, poor treatment compliance, resistance, and defensiveness are the most common barriers to treatment for NPD.⁷ There is no cure for narcissism, but therapy can help a narcissist reduce or manage their symptoms.

Therapies for narcissistic personality disorder may include:^1,4,7

• Cognitive behavioral therapy (CBT): CBT is a structured therapy used to help people adjust their thinking patterns and make behavioral changes. CBT can assist them in reaching their goals and improving their level of functioning.
• Metacognitive interpersonal therapy (MIT): In MIT, clients learn how to better respond to negative emotions by introducing specific skills to help regulate emotions, improve decision-making, and communicate more effectively.
• Dialectical behavioral therapy (DBT): DBT teaches clients mindfulness, distress tolerance, and interpersonal communication skills in order to manage and regulate emotions. Those with NPD can use these skills to control rage and other negative feelings.
• Psychoanalytic therapy: In this type of therapy, the person with NPD will explore past experiences to understand what may contribute to their narcissistic behaviors. A therapist will also help them identify assumptions or beliefs they have about themselves that perpetuate these behaviors.
• Family therapy: In family therapy, a trained therapist will focus on problems affecting familial relationships rather than the narcissist’s individual issues.
• Couples therapy: Couples therapy should be approached cautiously, as narcissists often put on a facade with a therapist. However, combined with individual therapy, couples therapy can help a narcissist understand the dysfunction their actions cause in the relationship.
• Schema therapy: Schema therapy helps those with NPD shift old, unhelpful, and limiting beliefs they hold about themselves, others, and the world. During sessions, a client works to identify and heal the impacts of past traumas, reduce defensiveness, and learn methods of responding to triggers.
• Group therapy: Group therapy can assist narcissists in exploring their internal beliefs and learning how to receive feedback in healthy ways.

Medication for NPD

There are no approved medications for narcissistic personality disorder.⁴ However, many individuals living with NPD may have underlying mental health disorders, such as substance use disorders, mood disorders, and anxiety disorders, that lead them to seek treatment.⁷ As opposed to therapy alone, many of these conditions may respond better to a combination of therapy and medication (i.e., an antidepressant or anti-anxiety medication).¹

Can a Narcissist Change?

A narcissist can change, but this process is only possible if the narcissist is sincere and willing to change.^4,7 Their negative narcissistic traits, symptoms, and defenses can further interfere with treatment. In order to make necessary improvements, extensive individual or family therapy (and sometimes medication) is essential.^1,4,7

Living & Coping With NPD

In addition to seeking treatment, there are lifestyle changes a person with NPD can make to help them manage and reduce their symptoms. Developing positive coping skills, exploring creative outlets, and pursuing positive activities are a few avenues to try out.

Below are tips for coping with narcissistic traits and symptoms:

• Seek emotional support: Prioritizing quality time with loved ones and relying on them for emotional support is important when addressing narcissistic tendencies.
• Learn how to accept feedback: Become better about asking for and accepting feedback from others, even if it’s difficult to hear.
• Channel your emotions in healthy ways: Journaling, exercising, and building your support network are all ways to manage emotions and urges.
• Set and maintain boundaries: Be sure to set boundaries with a narcissist at work and in relationships to avoid the build-up of stress, anger, and resentment that can contribute to symptoms.
• Introduce mindfulness into your life: Try a mindfulness or meditation routine to improve your mood, boost your energy and focus, and reduce your stress levels.
• Take a step back from online accounts: Taking regular breaks from social media, dating apps, and other self-focused websites can help you develop a more internal sense of validation.
• Work on your self-awareness: Talking about or reflecting on your thoughts, feelings, goals, and values can help you build your self-awareness.
• Be gentle with yourself as you make changes: Positive self-talk and self-compassionate are important for everyone. When you’re feeling insecure, remember to speak kindly to yourself.

How to Stop Being a Narcissist

If you’re already self-reflecting on your narcissistic traits, this self-awareness will go a long way in helping you stop being a narcissist. Continue focusing on noticing when you display narcissistic behaviors. Ask yourself, “What triggers me to go into a rage” or “What makes me want to be admired constantly”? Noticing the precursors to these behaviors can help you understand your patterns.

Consistently maintain and work on your self-compassion and becoming okay with being vulnerable. Attend therapy regularly and use the skills learned in sessions to make long-lasting, positive changes in yourself and your life.

How to Help a Narcissist

It’s natural to want to help the narcissist in your life. However, setting boundaries beforehand to protect your mental health and well-being is crucial. A stable support system and strong coping skills will help you avoid becoming a source of narcissistic supply or victim of narcissistic abuse.

Below are tips for helping a narcissist:

• Remain empathetic: It can be difficult to feel compassion toward someone if they do not treat you with respect. Still, remember that a narcissist’s actions often stem from trauma and are not the result of something you said or did.
• Encourage treatment: Encourage and support the narcissist in your life to seek the treatment they need to heal their trauma and inner wounds.
• Support them in therapy: Going to therapy can make a narcissist feel vulnerable and trigger unwanted behaviors. Support them as they process these feelings by offering a safe space to vocalize and share with you outside of sessions.
• Hold them accountable: Remain strong and point out when they fall back into old patterns that are hurtful or destructive.
• Remain respectful: Avoid acting out in tense moments by saying or doing something that makes the situation worse.
• Use “I” statements: Narcissists want to make everything about themselves. Using “I” statements allows you to be clear about how their behaviors impact and make you feel.

How to Manage Living With a Narcissist

Living with a narcissist can leave you feeling ashamed, invalidated, and underappreciated. It can be incredibly frustrating to share a space with a narcissist, especially if you do not have a source of support in the home. Remember to maintain your boundaries, learn how to say “no,” and stand up for yourself.

Here are tools to help if you live with a narcissist:

• Prioritize self-care: You won’t be able to stick to your boundaries and practice healthy coping skills if you allow your self-care to be overlooked.
• Utilize relaxation techniques: Relaxing and soothing yourself helps you remain in the best frame of mind when facing difficult situations. It also strengthens your response to stress in the future.
• Build your self-esteem: Narcissists feed off of people who have low self-worth. Building your self-esteem and confidence helps you recognize when a narcissist is attacking you with lies about your character.
• Establish boundaries: Setting boundaries means clearly stating what you are and are not okay with, what you’re willing to tolerate, and what the consequences are if boundaries are crossed.
• Maintain your boundaries: Always continue to enforce boundaries after establishing them. This ensures that you are serious, as a narcissist will likely push back on your limits whenever possible.
• Learn more about NPD: Educate yourself about narcissism to become familiar with how narcissistic behaviors manifest in your relationship with a narcissist.
• Recognize the signs of NPD: Recognizing the signs of NPD helps you protect yourself, take action when needed, and know when it’s time to disengage.
• Know when to leave: You never have to subject yourself to an unsafe or unhealthy situation. If your boundaries and values are continuously ignored, know it’s okay to move on.

Final Thoughts

Narcissism is poorly understood and highly stigmatized. However, with the help of a therapist, those with narcissistic personality disorder can learn how to build true self-worth, reduce their dependence on external sources, and manage their symptoms. They can heal their underlying shame and unlearn many toxic defense mechanisms that drive their behavior when an authentic effort is made.