Narcissistic Personality Disorder: Signs, Symptoms, & Treatments

Narcissistic personality disorder (NPD) is a personality disorder characterized by arrogance, self-importance, and grandiosity.^1,2,3 People with NPD rely almost entirely on external sources of validation to maintain their self-esteem and alternate between extreme pride and shame.^4,5,6 NPD can be difficult to treat, but individual and family therapy can be beneficial for those with a true desire to manage their condition.^4,7

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What Is Narcissistic Personality Disorder?

Narcissistic Personality Disorder is one of ten diagnosable personality disorders, characterized by a grandiose sense of self and a lack of empathy.³ Unlike other forms of mental illness, personality disorders affect a person’s personality traits and distort their understanding of themselves. All personality disorders also affect a person’s relationships and friendships, often causing them to be less able to relate, connect, and form healthy trusting bonds with others.^4,7

Because people with NPD don’t know how to validate themselves or find worth internally, they are overly focused on how they are seen, perceived, and treated by others.⁷ They rely on external attention, praise, and validation to feel special or important and can collapse, becoming defensive, reactive, and even destructive when they do not get external validation (their form of supply).^4,6

When they don’t get enough external validation, their ego quickly deflates and their personal insecurities and shame are exposed. This is called a narcissistic injury, which often leads to defensive and aggressive reactions from a person with NPD (narcissistic rage). These defense mechanisms can get in the way of being able to form and maintain healthy, close relationships with other people.^4,7,8

Can There Be Healthy Narcissism?

There is a form of narcissism that is considered normal and even healthy. Healthy narcissism is a term sometimes used to describe a person who has high self-esteem, a lot of confidence, and a positive but realistic view of themselves. Unlike other forms of narcissism, this type does not cause problems or consequences in the person’s life, relationships, or their ability to function.

How to Spot a Narcissist: 15 Narcissistic Traits & Tendencies

It’s important to note that it’s possible to have certain narcissistic traits and tendencies without having a diagnosis of NPD. In fact, most people display at least some of the traits of a narcissist, but at most, it is estimated that only 5-6% of the population are actually diagnosed with NPD.^3,5,7,9

Still, people who have many of the traits and tendencies listed below may want to consider making an appointment with a licensed health or mental health professional to confirm whether or not they have NPD.

Here are 15 signs of a narcissist:^1,3,6,7

1. Excessive need for praise, attention, or external validation
2. Actively seeking out sources of external validation
3. Extreme sensitivity to criticism, rejection, and negative feedback
4. An inflated ego or extreme self-confidence
5. Inability to take responsibility for their feelings and actions
6. A tendency to make everything about themselves
7. Entitlement and becoming angry when not given special treatment
8. Projection of anger and blame onto others
9. Preoccupation with money, success, fame, power, or importance
10. Being overly concerned about appearance or reputation
11. Being overly competitive, jealous, or needing to ‘one-up’ others
12. Transactional relationships based on what others can do for them
13. Being condescending to others or always needing to be right
14. Holding grudges and seeking revenge
15. Moodiness and impulsive decision making

Types of Narcissistic Personality Disorder

The DSM 5 the standard reference guide for diagnosing all mental health conditions) doesn’t formally recognize NPD subtypes, but many experts believe they exist.^2,3,5,9 Different kinds of narcissism can lead people to display different traits, tendencies, symptoms and behaviors.

The following narcissistic personality disorder subtypes have been identified in research:^2,4,5,9

• Grandiose narcissism (also called overt narcissism or classic narcissism): The overt or grandiose narcissist often fits the stereotype of what most people think of as NPD. People with this subtype tend to be self-important, arrogant, boastful, extroverted people who actively seek out praise, attention, and validation.
• Vulnerable narcissism (also called covert narcissism or fragile narcissism): The covert or vulnerable narcissist is harder to spot because they may be more quiet, shy, or reserved in nature, especially when they are insecure or upset. They often struggle with low self esteem and shame, and may appear as moody, needy, and brooding types.
• Communal narcissism: Communal narcissism is a newer subtype that some researchers believe exists. Perhaps the hardest to detect, this subtype appears selfless, generous, and even humble to others, and tends to dedicate a lot of time and energy into other people, causes that benefit their communities, or other high-profile charities. Unlike the other subtypes, they get their validation and attention by competing to be seen as the most giving and selfless, when they really feed on the attention these actions get them.
• Malignant narcissism: Malignant narcissism is a term used to describe a person who displays traits and tendencies of both Narcissistic Personality Disorder and Antisocial personality Disorder. This dangerous combination can lead people to abuse, manipulate, and exploit other people for their own personal gain or pleasure.

Narcissistic Personality Disorder Symptoms

All personality disorders are diagnosed using a standardized set of symptoms taken from the DSM 5, the clinical reference book for all mental health conditions.

According to the DSM 5, a person who has NPD will experience five or more of these symptoms:³

1. A sense of grandiosity or excessive self-importance
2. Recurrent fantasies of being powerful, successful, beautiful, or important
3. Beliefs of being special and exceptional (and seeking out people of similar or higher ‘status’ or ‘importance’ as them)
4. Excessive need for validation, praise, and admiration from others
5. A sense of entitlement or feeling like they deserve special treatment
6. Exploiting others for personal gain or selfish reasons
7. Lacking in empathy or unwilling to identify with the needs of others
8. Being envious of others or believing others are envious of them
9. Arrogant or haughty behavior, acting better than others

Narcissism & Relationship Challenges

Relationships are among the most common areas of life that can be negatively impacted by NPD. People with NPD often find it difficult to form healthy, reciprocal, close relationships with other people. They often find it difficult to connect with people because of their underlying issues with self-esteem and their overuse of defense mechanisms and narcissistic sayings that tend to push people away.

A narcissist in a relationship might:^2,4,5,6,8

• Blame others or project anger outwards
• Deny any responsibility or accountability for their actions
• Be righteously indignant or act in a demanding or entitled way
• Gaslight to distort the truth and get the other person to doubt themselves
• Launch personal attacks or become aggressive or cruel
• Try to turn other people against someone
• Devalue relationships, cut ties, and discard people
• Refuse to admit or experience vulnerable emotions (i.e. sadness, fear, etc.)
• Gather facts selectively to maintain a positive self-view
• Have grandiose beliefs or fantasies about unlimited power, wealth, or importance
• Engage in impulsive or destructive behaviors for instant gratification
• Seek revenge against people they believe have wronged or slighted them
• Seek attention to try to gain external validation
• Use or exploit people for personal gain or selfish reasons
• Become overly jealous, controlling, or possessive of others
• Always be on the lookout for someone or something better

Many people in romantic relationships with someone who has NPD shows signs of narcissistic abuse, and may suffer long-term psychological trauma as a result. Relationships with people with NPD are often unhealthy, toxic, codependent, or even abusive in nature.

*If you need more information about interpersonal violence or need help getting out of an abusive relationship, consider reaching out to this free 24 hour hotline, calling 911 (if you’re in danger), or looking for domestic violence shelters in your area.

Can a Narcissist Change?

A narcissist can change, but the process can be difficult and slow. When a person with NPD has a sincere desire to change, they often find that their traits, symptoms, and defenses can interfere with the process.^4,7 Extensive treatment involving individual and/or family therapy (and sometimes medication to treat underlying conditions) is often needed.^1,4,7

When someone with NPD seeks treatment for their condition, their likelihood of making progress can increase when:^1,4,7

• They have an active support system
• A friend, loved one, or partner is involved in their treatment
• They are compliant and stay in treatment long-term
• There is a strong alliance with their therapist
• Underlying mental health or substance use problems are treated at the same time
• There is readiness and willingness to change behaviors
• The therapist providing treatment is knowledgeable about NPD
• They are receptive and open to feedback and guidance from the therapist
• Self-efficacy and internal validation is a major focus of treatment
• Empathy, communication, and impulse control skills are applied

Treatment of Narcissistic Personality Disorder

All personality disorders are complex and hard to treat, but NPD is often viewed as one of the most difficult to treat. Narcissistic tendencies can lead people to become less likely to seek treatment, and also less likely to complete treatment.^1,4,7

People with NPD who do seek treatment may do so only after being coerced by a partner or when seeking help for an underlying issue or problem. The traits and symptoms of NPD can interfere significantly with treatment, causing people to become angry, defensive, and less receptive to the efforts of the therapist.^4,6,7,8

Still, nobody is beyond help. A person who has narcissistic personality disorder or even NPD traits who sincerely wants help and is willing to do the hard work of looking within can get better. Seeking out a therapist who is compassionate, knowledgeable, and skilled at treating personality disorders (and especially NPD) is often the first step in the process.^1,4

Therapy for Narcissism

There are no specific types of therapy only used to treat NPD, and no peer-reviewed, controlled studies have been done to identify effective treatments.⁴ Dropout and poor treatment compliance are among the most common barrier to treatment for NPD, as well as unhelpful resistance and defensiveness that undermines the therapeutic process.⁷

Here are six common types of therapy that may help people with NPD reduce or manage their symptoms:^1,4,7

1. Cognitive Behavioral Therapy (or CBT) which is a structured kind of therapy used to help people adjust their thinking patterns and make behavioral changes that help them reach their goals and improve their level of functioning.
2. Mindfulness based therapies like Metacognitive Interpersonal Therapy or Acceptance and Commitment Therapy (or ACT) can help people respond more skillfully when they experience negative emotions by teaching specific skills to help regulate emotions, improve decision making, and communicate more effectively.
3. FRAMES (an acronym for Feedback, Responsibility, Advice, Menu of strategies, Empathy, and Self-efficacy) is a newer therapy approach specifically designed for people with personality disorders. This therapy approach helps to maximize progress and support positive behavioral change in clients with NPD.
4. Supportive therapies like Person-centeredness and psychodynamic therapy are the basis of many modern therapeutic approaches. Both aim to build a strong, trusting bond between the client and therapist which is proven to increase the success of treatment for clients with NPD.
5. Family or couples therapy is another option for people who are experiencing family or relationship conflict as a result of NPD traits or symptoms. In family or couples therapy, a trained therapist will focus more on problems affecting the relationship, rather than problems only affecting one person.
6. Schema Therapy is another type of therapy that focuses on helping people with NPD change old, unhelpful, and limiting beliefs about themselves, others and the world. This kind of therapy utilizes elements of CBT, attachment therapy, and psychoanalytic therapy to help people identify and heal the impacts of past traumas, reduce defensiveness, and learn better methods of responding when triggered.

A very high percentage of people with NPD suffer from another mental illness or substance use disorder, and may benefit from treatments that can target the symptoms of these conditions as well.⁷ Because many people with NPD have experienced trauma in their childhood, they may benefit from trauma-informed therapies.¹⁰

Medication for NPD

There are no approved medications for narcissistic personality disorder.⁴ Still, many individuals living with NPD have another underlying mental health or substance use disorder, with mood disorders, anxiety disorders, and addictive disorders being the most common.⁷ Many of these conditions may respond better to a combination of therapy and medication (i.e. an antidepressant or anti-anxiety medication), as opposed to therapy alone.¹

If you have or suspect you have an underlying condition that may require medication, you will need to schedule an appointment with a medical doctor, psychiatrist, or other prescribing professional. Most therapists, psychologists, and social workers do not have the ability to prescribe medication, although some may work in practices that provide medication services on-site.

Treatment Timeline & Expected Outcomes

While many disorders respond quickly to short-term therapies, treatment for personality disorders is more involved, and often requires long-term maintenance. Full remission of NPD may not be a realistic expectation, but people can often learn to better manage their symptoms and improve their functioning with help from a therapist.^1,4,7

Treatment for NPD can be difficult, as open and honest conversations about the person’s past, life, work, and relationships can trigger shame and cause urges to use many of the problematic defense mechanisms common in NPD. People who are seeking treatment for narcissistic symptoms or traits will need to avoid using these defenses and become willing to be honest, vulnerable, and receptive to their therapist in order to get the help they need.

Living & Coping With Narcissistic Traits & Symptoms

In addition to seeking treatment for NPD from a qualified therapist, there are other lifestyle changes a person with NPD can make that can help them manage and reduce their symptoms and stop their narcissistic behaviors. These include the use of positive coping skills, outlets, and activities that have been proven to reduce stress and improve mental well-being.

Here are nine tips for coping with narcissistic traits and symptoms:¹

1. Prioritize quality time with friends and family and rely on these people for emotional support when you need it
2. Become better about asking for and accepting feedback from other people, including negative or difficult feedback
3. Learn to manage your emotions and urges in healthy ways (i.e. journaling, exercise, talking to others) instead of projecting, avoiding, or acting on them
4. Set clear boundaries at work and in relationships to avoid the build-up of stress, anger, and resentment
5. Start a mindfulness or meditation routine to improve your mood, boost your energy and focus, and reduce your stress levels
6. Establish healthy eating, sleeping, and exercise routines to regulate mood & energy, reduce toxic stress, and improve your overall health
7. Take regular breaks from social media, dating apps, and other apps or websites that are self-focused, superficial, or provide external validation
8. Develop more self-awareness through journaling, talking, or reflecting on your thoughts, feelings, goals, and values
9. Improve your self-talk and be kinder and more compassionate with yourself, especially when you’re feeling insecure, upset, or have made a mistake

How to Get Help for Narcissistic Personality Disorder

The only way to confirm a diagnosis of NPD is to make an appointment with a licensed health or mental health professional. During an initial evaluation and assessment, a trained clinician (could be a licensed psychologist, counselor, social worker, or even a psychiatrist) will be able to diagnose you and make recommendations for treatment.

Many people begin their search for a therapist online by conducting a google search or using a free online therapist directory to help match them to a local therapist who has certain specialties. People with health insurance or Employee Assistance Program benefits can often save money by finding an in-network therapist. To find an in-network provider, you can call the number on the back of your card or use the filters in the directory to narrow your search.

Getting Help for a Loved One With NPD

It can be difficult to get a loved one to agree to treatment, especially if they are struggling with narcissistic traits. Offering to engage in family or couples therapy with them can sometimes help, but you may still find they are resistant to the idea. Unless the person is posing a serious danger to themselves, you, or others, you cannot force them into treatment against their will.

Like many personality disorders, NPD is generally not diagnosed in people under the age of 18. It is more likely that the child or teen displaying narcissistic symptoms is struggling with another emotional or behavioral issue. Certain narcissistic traits are common and even developmentally appropriate in children and teens, and most will outgrow them and not go on to develop NPD.

Narcissistic Personality Disorder Statistics & Facts

In recent years, the number of people being diagnosed with NPD has grown.² More people are displaying traits, tendencies, and symptoms of narcissism, which has been puzzling for researchers.

Here are some facts and statistics on Narcissistic Personality Disorder:^2,4,7,9,11

• It’s estimated that 5-6% of the population has NPD
• 50-75% of people diagnosed with NPD are males
• 87% of people diagnosed with NPD are Caucasian
• An estimated 40% of clients with NPD drop out early from treatment
• More than 40% of people with NPD have a substance use disorder
• 28.6% of people with NPD suffer from a mood disorder (i.e. depression, bipolar)
• 40% of people with NPD also are diagnosed with an anxiety disorder
• Having a co-morbid mental health or addictive disorder is linked to more severe NPD, and more serious life impairments related to NPD
• Individuals with NPD are more likely to report shame, helplessness, self-directed anger and impulsivity
• NPD is closely linked to suicide risk, with narcissistic individuals being more likely to attempt suicide, and more likely to use more deadly means to attempt suicide
• People with NPD have higher rates of criminal involvement
• People with NPD are more likely to report anger management issues, aggression and feelings of hatred, and are more likely to act abusively towards partners
• Rates of NPD decline with age, with people being more likely to be diagnosed in young adulthood, and rates of NPD diagnosis dropping significantly in the late 20’s
• People with high extraversion and neuroticism (personality traits) are more likely to develop grandiose narcissism, while introverted people are more likely to develop vulnerable narcissism
• Grandiose (overt) narcissists are usually higher-functioning than vulnerable (covert) narcissists

Tests & Self-Assessments for NPD

There are many assessment tools that clinicians may utilize to help pinpoint a diagnosis of NPD. Some of these assessments are available to the public, but should only be used for screening purposes. The only way to confirm a diagnosis of NPD is to schedule a formal diagnostic assessment with a properly licensed, trained, and credentialed medical or mental health professional.

Some of the more common assessment tools used to identify symptoms and traits of NPD include:

• The Pathological Narcissism Inventory (PNI)
• The Brief Pathological Narcissism Inventory (B-PNI) (shorter version of above)
• The Narcissistic Personality Inventory (NPI)

Final Thoughts

Narcissistic personality disorder is a personality disorder that affects about 5-6% of the population.^3,7,9 People with NPD seek out external validation in an attempt to correct insecurities and deep-seated feelings of shame, but then use defense mechanisms that end up making their problems worse.

NPD can be difficult to treat, especially since many of the symptoms cause people to be defensive and resistant to any help or advice from others. If there is another underlying mental health or substance use condition, it is also important to address these issues in therapy as well, and may also require the addition of psychiatric medication.

Narcissism is poorly understood and highly stigmatized, but many people display at least some traits and tendencies. With the help of a therapist, people with narcissistic traits can often learn how to build true self-worth, reducing their dependence on external sources. When there is an authentic effort made, people with NPD can heal the underlying shame and unlearn many of the toxic defense mechanisms that drive the disorder.

Additional Resources

Education is just the first step on our path to improved mental health and emotional wellness. To help our readers take the next step in their journey, Choosing Therapy has partnered with leaders in mental health and wellness. Choosing Therapy may be compensated for referrals by the companies mentioned below.

Narcissist Abuse Support Groups – Circles offers support groups that provide a safe place to share your experiences and learn from others going through similar experiences. Groups bring together people based on their relationship with the narcissist, like those who have been involved in a romantic relationship with a narcissist. Groups meet weekly by video and are led by expert facilitators. Learn More

BetterHelp (Online Therapy) – BetterHelp has over 20,000 licensed therapists who provide convenient and affordable online therapy. BetterHelp starts at $60 per week. Complete a brief questionnaire and get matched with the right therapist for you. Get Started

Online-Therapy.com – The Online-Therapy.com standard plan includes a weekly 45 minute video session, unlimited text messaging between sessions, and self-guided activities like journaling. Recently, they added Yoga videos. Get Started

Headspace (Meditation App) – Headspace is the leading mindfulness and meditation app with over 70 million members. Headspace offers guidance and exercises for all skill levels, including beginners. Free Trial

Choosing Therapy’s Directory – Find an experienced therapist who is committed to your wellbeing. You can search for a therapist by specialty, availability, insurance, and affordability. Therapist profiles and introductory videos provide insight into the therapist’s personality so you find the right fit. Find a therapist today.

Choosing Therapy partners with leading mental health companies and is compensated for referrals by Circles, BetterHelp, Online-Therapy.com, and Headspace

For Further Reading

• Best Books on Narcissism
• University of Wollongong’s Project Air dedicated to research and innovation on personality disorders
• Fact sheet on narcissistic personality disorder 
• Mayo Clinic website with information on NPD
• Popular TED talks on narcissism:
  • The Psychology of Narcissism
  • Narcissism and its discontents 
  • Managing a Narcissist

Narcissistic Personality Disorder Infographics