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Narcissistic Personality Disorder Differential Diagnoses

  • Author: Sheenie Ambardar, MD; Chief Editor: David Bienenfeld, MD  more...
Updated: May 09, 2016

Diagnostic Considerations

Narcissistic personality disorder (NPD) is 1 of the 4 cluster B personality disorders, which also include antisocial personality disorder (ASPD), borderline personality disorder (BPD), and histrionic personality disorder (HPD). Whereas NPD is a distinct entity, it shares many similarities with the other cluster B disorders, which can be concomitantly diagnosed if the appropriate diagnostic criteria are met. It is therefore important to be aware of the salient differences among the cluster B personality disorders.[1]

Borderline personality disorder

BPD and NPD are both characterized by a constant need for attention, as well as affective instability and unpredictable behavior. However, the patient with NPD has a much greater sense of grandiosity than the patient with BPD and requires attention that is specifically of the admiring kind. The patient with BPD also demonstrates more self-destructive behaviors (eg, cutting and self-mutilation) and has a much less stable sense of self than the patient with NPD does.[17]

Antisocial personality disorder

ASPD and NPD are both characterized by a disregard for the needs and feelings of others and a disturbing lack of empathy. However, ASPD is characterized by repeated transgressions with the law, physical aggressiveness, and a history of conduct disorder in childhood, which generally are not seen in NPD. Patients with narcissism are also more grandiose and arrogant than patients who are antisocial.[18]

Histrionic personality disorder

HPD and NPD are both marked by attention-seeking behavior; however, people with narcissism specifically require attention that is adulatory. In addition, patients with HPD are comparatively more needy and emotionally demonstrative than patients with NPD, who are usually cold and impersonal.

Axis I disorders

Patients with NPD may also meet criteria for separate axis I diagnoses (eg, major depressive disorder, bipolar disorder, or a substance-related disorder). Alternatively, patients with only NPD may at times have symptoms that mimic those of axis I disorders, such as grandiosity that is mistaken for the mania or hypomania of bipolar disorder.[19]

It is therefore important to ascertain the exact nature and duration of the symptoms, keeping in mind that personality disorders are associated with long-standing, chronic patterns of behavior rather than isolated episodes of transient pathology.

Differential Diagnoses

Contributor Information and Disclosures

Sheenie Ambardar, MD Adult Psychiatrist, Private Practice

Sheenie Ambardar, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.


Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment


Dr. Ambardar would like to thank Dr. Donald C. Fidler, Farnsworth Endowed Chair of Psychiatric Education at West Virginia University, for generously granting permission to use his video clip in the multimedia section of this article.

  1. American Psychiatric Association. Personality disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing, Inc; 2013.

  2. American Psychiatric Association. Alternative DSM-5 model for personality disorders. Fifth Edition. Washington, DC: American Psychiatric Publishing, Inc; 2013. 761-81.

  3. Akhtar S, Thomson JA Jr. Overview: narcissistic personality disorder. Am J Psychiatry. 1982 Jan. 139(1):12-20. [Medline].

  4. Torgersen, S. Epidemiology. Oldham JM, Skodol AE, Bender DS. The American Psychiatric Publishing Textbook of Personality Disorders. Washington, DC: American Psychiatric Publishing; 2005. 129-141.

  5. de Ruiter C, Greeven PG. Personality disorders in a Dutch forensic psychiatric sample: convergence of interview and self-report measures. J Pers Disord. 2000 Summer. 14(2):162-70. [Medline].

  6. Ronningstam E. Narcissistic Personality Disorder: Facing DSM-V. Psychiatric Annals. 2009 Mar. 39:111-121.

  7. Crosby RM, Hall MJ. Psychiatric evaluation of self-referred and non-self-referred active duty military members. Mil Med. 1992 May. 157(5):224-9. [Medline].

  8. Bourgeois JA, Hall MJ, Crosby RM, Drexler KG. An examination of narcissistic personality traits as seen in a military population. Mil Med. 1993 Mar. 158(3):170-4. [Medline].

  9. Maffei C, Fossati A, Lingiardi V, Madeddu F, Borellini C, Petrachi M. Personality maladjustment, defenses and psychopathological symptoms in non-clinical subjects. J Pers Disord. 1995 Apr. 9:330-345.

  10. Rebecca J. Frey, Ph.D. Narcissistic Personality Disorder. Encyclopedia of Mental Disorders. Available at Accessed: September 8, 2008.

  11. Ronningstam E, Gunderson J, Lyons M. Changes in pathological narcissism. Am J Psychiatry. 1995 Feb. 152(2):253-7. [Medline].

  12. Waller G, Sines J, Meyer C, et al. Narcissism and narcissistic defences in the eating disorders. Int J Eat Disord. 2007 Mar. 40(2):143-8. [Medline].

  13. Ronningstam E. Pathological narcissism and narcissistic personality disorder in Axis I disorders. Harv Rev Psychiatry. 1996 Mar-Apr. 3(6):326-40. [Medline].

  14. Ronningstam EF, Maltsberger JT. Part X: Personality Disorders. Gabbard GO. Gabbard's Treatments of Psychiatric Disorders. Fourth Edition. Washington DC: American Psychiatric Publishing; 2007. Chapter 52: Narcissistic Personality Disorder, pages 791-804.

  15. David Bienenfeld, MD. Personality Disorders. Medscape Reference. Available at Accessed: July 1, 2008.

  16. Simon RI. Outpatients. Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington DC: American Psychiatric Publishing; 2004. 89-90.

  17. Holdwick DJ Jr, Hilsenroth MJ, Castlebury FD, et al. Identifying the unique and common characteristics among the DSM-IV antisocial, borderline, and narcissistic personality disorders. Compr Psychiatry. 1998 Sep-Oct. 39(5):277-86. [Medline].

  18. Gunderson JG, Ronningstam E. Differentiating narcissistic and antisocial personality disorders. J Personal Disord. 2001 Apr. 15(2):103-9. [Medline].

  19. Stormberg D, Ronningstam E, Gunderson J, et al. Brief communication: pathological narcissism in bipolar disorder patients. J Personal Disord. 1998. 12(2):179-85. [Medline].

  20. Clarkin JF, Howieson DB, McClough J. The Role of Psychiatric Measures in Assessment and Treatment. Hales RE, Yudofsky SC, Gabbard GO. The American Psychiatric Publishing Textbook of Psychiatry. 5th Edition. Arlington, VA: American Psychiatric Publishing; 2008. Chapter 3.

  21. Roth BE. Narcissistic patients in group therapy: containing affects in the early group. Ronningstam E. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Washington DC: American Psychiatric Press; 1998. 221-238.

  22. Alonso A. The shattered mirror: treatment of a group of narcissistic patients. Group. 1992 Dec. 16:210-219.

  23. Young J, Flanagan C. Schema-focused therapy for narcissistic patients. Ronningstam E. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Washington DC: American Psychiatric Press; 1998. 239-268.

  24. Young J, Klosko JS, Weishaar ME. Schema Therapy. A Practitioner's Guide. New York: Guilford; 2003.

  25. Links PS, Gould B, Ratnayake R. Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry. 2003 Jun. 48(5):301-10. [Medline].

  26. Links PS, Kolla N. Assessing and Managing Suicide Risk. Oldham JM, Skodol AE, Bender DS. The American Psychiatric Publishing Textbook Of Personality Disorders. Washington DC: American Psychiatric Publishing; 2005. 459.

This is an actor portrayal of a patient with narcissistic personality disorder. This video clip was provided courtesy of Donald C. Fidler, MD, FRCP-I.
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