Narcissistic Personality Disorder

Narcissistic personality disorder (NPD) is 1 of the 10 clinically recognized personality disorders listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders,Fifth Edition, Text Revision (DSM-5-TR). It belongs to the subset of cluster B personality disorders, which are those marked by an intense degree of drama and emotionality. Historically, there has been much debate surrounding the exact definition of NPD, and competing theories exist regarding its etiology and optimal treatment.

Diagnostic criteria (DSM-5-TR)

In DSM-5-TR, NPD is defined as comprising a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by the presence of at least 5 of the following 9 criteria:[1]

• A grandiose sense of self-importance (eg, the individual exaggerates achievements and talents and expects to be recognized as superior without commensurate achievements)

• A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love

• A belief that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people or institutions

• A need for excessive admiration

• A sense of entitlement (ie, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations)

• Interpersonally exploitive behavior (ie, the individual takes advantage of others to achieve his or her own ends)

• A lack of empathy (unwillingness to recognize or identify with the feelings and needs of others)

• Envy of others or a belief that others are envious of him or her

• A demonstration of arrogant and haughty behaviors or attitudes

These official diagnostic criteria are unchanged from the previous DSM edition. 

The exact mechanism by which narcissistic personality disorder (NPD) develops is unknown. Biologic, psychological, social, and environmental factors all probably play a role, but further research is necessary to confirm this supposition. Several psychodynamic theories point to an unhealthy early parent-child relationship as salient in the development of the disorder. To date, no genetic links to the disorder have been determined, but future research into the biologic basis of personality disorders may yield more information on the origins of NPD.

From a psychoanalytic standpoint, the 2 main schools of thought regarding the origins of the disorder are the object-relations model described by Otto Kernberg and the self-psychology model developed by Heinz Kohut. Both models posit that an inadequate relationship between parent and child lays the groundwork for the eventual development of NPD.

According to Kernberg, NPD is the result of a young child having an unempathetic and distant mother who is hypercritical and devaluing of her child.[3] As a defense against this perceived lack of love and to guard against emotional pain, the child creates an internalized grandiose self. Kernberg believed that this grandiose self was a combination of the following 3 elements:

• The child’s own positive traits

• A fantastical, larger-than-life version of himself or herself

• An idealized version of a nurturing mother

In keeping with the object-relations model, on which Kernberg based much of his theory, the child eventually splits off the unlovable and needy image of himself or herself and relegates it to the unconscious, where it later forms the basis for the fragile self-esteem and sense of inferiority present in NPD.[3]

By contrast, Heinz Kohut felt that NPD was the result of a developmental arrest in normal psychological growth.[3] He maintained that narcissism is a natural feature of the young child, who is bound to think of himself or herself as the center of the universe.

According to Kohut, through the twin processes of mirroring (whereby the parent provides appropriate praise) and idealization (whereby the child effectively internalizes positive parental images), a child without narcissism can temper his or her former sense of being the center of the universe. However, if the parents do not offer effective mirroring or do not provide a basis for idealization, the child will be stuck with his or her initial grandiose, wholly unrealistic sense of self, and this developmental arrest will eventually lead to NPD.[3]

United States statistics

It is estimated that narcissistic personality disorder (NPD) is present in 0.5% of the general United States population[4] and in 2-16% of those who seek help from a mental health professional. NPD is found in 6% of the forensic population,[5, 6] in 20% of the military population (the actual disorder as well as narcissistic traits),[7, 8, 6] and in 17% of first-year medical students.[9, 6]

International statistics

Outside the United States, NPD is not recognized as a separate diagnostic entity. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) lists only 8 personality disorders (as opposed to the 10 found in DSM-5). What DSM-5 defines specifically as NPD falls under the ICD-10 heading of “Other Specific Personality Disorders” or “eccentric, impulsive-type, immature, passive-aggressive, and psychoneurotic personality disorders.”[10]

Age-, sex-, and race-related demographics

NPD manifests by young adulthood (early to middle 20s) and may worsen in middle or old age as a consequence of the onset of physical infirmities or declining physical attractiveness. (In addition to feeling intellectually and socially superior to others, people who are narcissistic are often quite vain regarding their physical appearance.) Narcissistic traits can be exhibited by typical adolescents who are unlikely to go on to develop NPD.

NPD is more commonly found in males than in females; of those diagnosed with the disorder, approximately 75% are male. No racial or ethnic predilection has been identified.

The natural history of narcissistic personality disorder (NPD), like those of all personality disorders, is unfavorable, and the condition is typically lifelong. However, many patients can and do show improvement with appropriate treatment. Research also suggests that corrective life events, such as new achievements, stable relationships, and manageable disappointments, can lead to considerable improvement in the level of pathologic narcissism over time.[11]

Patients diagnosed with NPD are more likely to have comorbid axis I diagnoses, such as major depressive disorder, bipolar disorder, substance-related disorders (specifically related to cocaine and alcohol), anxiety disorders, and anorexia nervosa.[12, 13]

It is important to educate patients with narcissistic personality disorder (NPD) about the signs and symptoms of the disorder and explain to them in a supportive way that their behavior is a result of many different factors. During this psychoeducational phase of treatment, it is helpful to present patients with relevant reading material so that they may become aware of how the diagnosis specifically applies to them.[14]

There are a myriad of Web sites for patients seeking lay information about NPD, of which the following are representative examples:

• MayoClinic.com, Narcissistic Personality Disorder

• MedlinePlus, Narcissistic personality disorder

• WebMD.com, Mental Health: Narcissistic Personality Disorder

In addition, the following resources are available to patients who may have questions about NPD:

• National Alliance for the Mentally Ill (NAMI) (800-950-NAMI[6264])

• Mental Health America (800-969-6642)

Family education is also important, in that relatives and loved ones of people with NPD are often profoundly affected by the illness as well. The following books may be helpful for those who may be in close contact with people who have NPD:

• The Narcissistic Family: Diagnosis and Treatment - Stephanie Donaldson-Pressman and Robert M Pressman, Jossey-Bass, 1997

• The Wizard of Oz and Other Narcissists: Coping with the One-Way Relationship in Work, Love, and Family - Eleanor Payson, Julian Day Publications, 2002

• Trapped in the Mirror - Elan Golomb, Perennial Currents, 1995

Patients with narcissistic personality disorder (NPD) often present to the healthcare professional after hitting “rock bottom” in their careers or personal lives or at the strong urging of a family member who insists that they get professional help for their behavior.

Because NPD, by its nature, involves a haughty disregard for others and an insistence on one’s own innate superiority, narcissistic patients are unlikely to recognize their need for treatment and even less likely to seek help of their own accord. For this reason, patients with a diagnosis of NPD alone (ie, with no concomitant axis I diagnoses) make up a very small percentage of the total patient population seen by mental health professionals.

To be diagnosed with NPD, a patient must demonstrate a consistent and long-standing pattern of maladaptive behavior, starting in adolescence or early adulthood, that exemplifies 5 or more of the 9 criteria listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).[1] (See Overview.) Although many people display these criteria to some degree, NPD is diagnosed only when the symptoms are pervasive, debilitating, and socially and personally destructive.

Patients with NPD are also acutely sensitive to rejection or criticism and may avoid people or situations where there is the possibility of feeling “less than.” When criticized, such patients may become furious and lash out or withdraw into a shell of sullen hate. At their core, both of these reactions are thought to be due to intrinsically low self-esteem or a feeling of inferiority.[1]

Narcissistic personality disorder (NPD) is not associated with any specific defining physical characteristics.[15] However, physical consequences of the abuse of substances (particularly cocaine and alcohol), with which NPD is often associated, may also be apparent on examination.

Mental status examination (MSE) may reveal depressed mood due to dysthymia or major depressive disorder, both of which may be related to the paradoxically low self-esteem often present in patients with NPD. Conversely, patients in the throes of narcissistic grandiosity may display signs of hypomania or mania.[1]

The following is a sample MSE for a patient with NPD:

• General appearance and behavior - Well-groomed, well-dressed male in no acute distress

• Attitude - Resistant and haughty

• Psychomotor activity - Normal, no agitation or retardation

• Eye contact - Intense

• Affect - Restricted

• Mood - Angry

• Speech - Normal rate and tone, high volume; no pressured speech

• Thought process - No evidence of thought blocking, flight of ideas, loose associations, or ideas of reference; some tangentiality present

• Thought content - Denies suicidal ideation and homicidal ideation; denies audiovisual hallucinations; no paranoid delusions elicited or endorsed

• Orientation - Oriented to person, place, and time

• Attention and concentration - Good

• Insight - Poor

• Judgment - Limited

The video below includes an actor’s portrayal of an individual with NPD.

In general, patients with cluster B personality disorders (including narcissistic, borderline, antisocial, and histrionic personality disorders) are at substantially greater risk for suicide. In patients with narcissistic personality disorder (NPD) in particular, sudden life stressors (eg, job loss or unexpected financial misfortune) can lead to “surprise” or “shame” suicides.[16] Patients with NPD are also at increased risk for substance abuse—specifically, abuse of cocaine and alcohol.

No specific laboratory studies are employed to diagnose narcissistic personality disorder (NPD). Nevertheless, in view of the high incidence of substance abuse in patients with this disorder, it is wise to obtain a toxicology screen to rule out drugs and alcohol as possible causes of narcissistic character pathology.

The diagnosis of NPD is often made after obtaining a history of narcissistic symptoms from pertinent sources (including the patient, the patient’s family and friends, and the clinician’s own observations). However, more specific personality tests can also be used to facilitate diagnosis. There is some debate regarding the usefulness and reliability of these tests, but they can be helpful in elucidating character pathology outside the strict confines of the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).[1]

These personality tests are typically either self-report questionnaires given directly to the patient or semistructured interviews conducted by the clinician. Examples are the Personality Diagnostic Questionnaire–4 (PDQ-4), the Millon Clinical Multiaxial Inventory III (MCMI-III), and the International Personality Disorder Examination (IPDE). Each test uses a series of questions to determine the presence or absence of character pathology, and all may be valuable aids to the clinician trying to establish a formal diagnosis of NPD.[20]

Long-term, consistent outpatient care is the approach of choice in the treatment of narcissistic personality disorder (NPD). This usually involves a combination of psychotherapy and medication management.

The mainstay of treatment is individual psychotherapy—specifically, psychoanalytic psychotherapy. Other therapeutic modalities used to treat the disorder include group, family, and couples therapy, as well as cognitive-behavioral therapy (CBT) and short-term objective-focused psychotherapy.[14] Psychotropic medications are not specifically used to treat NPD but are often used to treat concomitant anxiety, depression, impulsivity, or other mood disturbances.

If the patient acutely decompensates or becomes a danger to self or others, inpatient treatment is warranted. As a rule, shorter hospital stays are best for patients with NPD; prolonged time in the hospital will do little to change the underlying severity of the illness. Hospitalization should only be used as a temporizing measure to allow stabilization of environmental stressors, adjustment of medication dosages, or both.[15]

Whereas individual psychoanalytic psychotherapy is the method of choice for the treatment of narcissistic personality disorder (NPD), there has been much debate as to exactly what constitutes optimal treatment. The 2 main schools of thought in this regard are Otto Kernberg’s object-relations approach and Heinz Kohut’s self-psychology approach, which offer different and seemingly contradictory ways of approaching the narcissistic patient.[14]

In Kernberg’s approach, the job of the therapist is to actively interpret the patient’s narcissistic defenses while at the same time illuminating the patient’s negative transferences. Kernberg believed that the end goal of therapy was to eradicate or diminish the patient’s pathologic grandiose self through direct confrontation.[14]

By contrast, Kohut advocated a more empathic approach, with the therapist actually encouraging the patient’s grandiosity and promoting the development of idealization in the transference. Kohut’s end goal was to bolster the patient’s inherently deficient self-structure.[14]

No definitive studies have strongly favored one therapeutic stance over another. Currently, most clinicians embrace a style that fuses elements of both. The general preference is for a flexible and moderate approach that combines an empathic understanding of the patient’s need for narcissistic defenses with a thorough exploration of those defenses.

In line with such an approach, the therapist should recognize the self-preserving role that narcissism plays in the patient’s daily life and should be cautious about tearing down narcissistic defenses too quickly. At the same time, the therapist should strive to help the patient gain a realistic understanding of his or her own behavioral deficiencies.[14]

Besides individual psychoanalytic psychotherapy, group therapy and CBT have also been used to treat NPD. Group therapy was initially thought to be unsuitable for patients with narcissism because clinicians assumed that these patients would be unable to handle the requisite give-and-take inherent in the group process.

This initial assumption about the unsuitability of group therapy was reasonable, in that group processes usually require empathy, patience, and the ability to relate and connect to others—traits are deficient in narcissistic individuals. Nevertheless, studies[21] have suggested that long-term group therapy can benefit patients with narcissism by providing them with a safe haven in which they can explore boundaries, receive and accept feedback, develop trust, and increase self-awareness.[21, 22]

CBT also has the potential to benefit narcissistic patients.[23] There is a specific form of CBT, known as schema-focused therapy, that centers on repairing narcissistic schemas and the defective moods and coping styles associated with them.[24] This highly active and work-intensive form of treatment encourages patients to confront narcissistic cognitive distortions (eg, black-and-white thinking and perfectionism) and has yielded some promising results in the treatment of NPD.[14]

No psychiatric medications are tailored specifically toward the treatment of narcissistic personality disorder (NPD). Nevertheless, patients with this disorder often benefit from the use of psychiatric medications to help alleviate certain symptoms associated with the disorder (eg, depression, anxiety, transient psychosis, mood lability, and poor impulse control). In addition, many patients with NPD have concomitant axis I diagnoses for which they are receiving regular psychiatric pharmacotherapy. Agents that may be indicated in the treatment of NPD patients include the following:

• Antidepressants of the selective serotonin reuptake inhibitor (SSRI) class (eg, citalopram)

• Antipsychotics (eg, risperidone)

• Mood stabilizers (eg, lamotrigine)

Clinicians cannot always easily gauge the potential for suicide in patients with narcissistic personality disorder (NPD) because these patients can become suicidal unexpectedly, even when they are not overtly depressed. Patients with narcissism can react brashly and dangerously to acute narcissistic injuries, which strike at the core of their low self-esteem.[25]

Accordingly, it is important for the clinician to monitor the NPD patient consistently, paying close attention to any unexpected life events that may catch the patient off guard. In addition, the patient’s access to potential means of suicide (eg, firearms and pills) should be limited.[26] As in any therapeutic relationship, the clinician should thoroughly document every aspect of the patient’s course of treatment, both to benefit the patient and to protect the clinician against any potential legal action.

Although no psychiatric medications are specifically approved for the treatment of narcissistic personality disorder (NPD), patients often benefit from the use of such medications to help alleviate certain symptoms associated with this disorder or to manage concomitant axis I diagnoses. Medications that may be considered include antidepressants (specifically, selective serotonin reuptake inhibitors [SSRIs]), antipsychotics, and mood stabilizers.

Class Summary

SSRIs such as citalopram may be used to treat depressive symptoms in adult patients with NPD. They are the antidepressants of choice because of their minimal anticholinergic effects. All are equally efficacious; selection depends on adverse effects and drug interactions. Determining whether the patient with NPD has a formal axis I diagnosis of major depression or depressive symptoms related to narcissistic pathology is important; this determination will influence the length and course of treatment.

Citalopram (Celexa)

Citalopram enhances serotonin activity through selective reuptake inhibition at the neuronal membrane. No head-to-head comparisons of SSRIs exist, though on the basis of metabolism and adverse effects, citalopram is considered the SSRI of choice for patients with head injury.

Escitalopram (Lexapro)

This agent is an SSRI and an S-enantiomer of citalopram that is used for the treatment of depression. Escitalopram enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Its mechanism of action is thought to be the potentiation of serotonergic activity in the central nervous system (CNS) through the inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief may occur after 1-2 weeks, which is faster than the relief obtained from other antidepressants.

Fluoxetine (Prozac)

Fluoxetine it selectively inhibits presynaptic serotonin reuptake with minimal or no effect on the reuptake of norepinephrine or dopamine.

Fluoxetine may cause more gastrointestinal adverse effects than other SSRIs now currently available. The drug may be administered in 1 dose or in divided doses. The presence of food does not appreciably alter levels of the medication. Fluoxetine may take up to 4-6 weeks to achieve steady state levels, as it has the longest half-life (72 h).

Fluoxetine's long half-life is an advantage and a drawback. If fluoxetine works well, an occasional missed dose is not a problem; if problems occur, eliminating all active metabolites takes a long time. The choice depends on adverse effects and drug interactions. Adverse effects of SSRIs seem to be quite idiosyncratic; thus, relatively few reasons exist to prefer one over another at this point if dosing is started at a conservative level and advanced as tolerated.

Fluvoxamine (Luvox CR)

Fluvoxamine enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than do tricyclic antidepressants.

Fluvoxamine has been shown to reduce repetitive thoughts, maladaptive behaviors, and aggression and to increase social relatedness and language use.

Sertraline (Zoloft)

Zoloft selectively inhibits presynaptic serotonin reuptake. It is indicated for obsessive-compulsive disorder in children aged 6-17 years.

Paroxetine (Paxil, Pexeva)

This would be unlabeled use. Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake.

For maintenance dosing, make dosage adjustments to maintain patient on lowest effective dosage, and reassess the patient periodically to determine the need for continued treatment.

Class Summary

Atypical antipsychotic agents such as risperidone may be used in adult patients with NPD to treat transient psychosis, mood lability, and poor impulse control. The response to antipsychotics is less dramatic than that seen in in true psychotic axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may be reduced. Antipsychotics are typically used for a short time while the symptoms are active.

Risperidone (Risperdal, Risperdal Consta IM Injection, Risperdal M-Tab)

Risperidone binds to dopamine D2 receptors with a 20 times lower affinity than that for serotonin 5-HT2 receptors. It mitigates negative symptoms of psychoses and reduces the incidence of extrapyramidal adverse effects.

Class Summary

Mood stabilizers such as lamotrigine may be used in adult patients with NPD to help with affect regulation and impulse control. The literature also contains some mention of the use of medications such as valproic acid and Lithium as mood stabilizers.

Lamotrigine (Lamictal)

Lamotrigine is an anticonvulsant that appears to be effective in the treatment of the depressed phase in bipolar disorders.

Valproic acid, divalproex sodium (Depakote, Depakene, Depacon, Stavzor)

Valproic acid is the most widely used agent in its class. It is modestly effective and generally well tolerated. It is chemically unrelated to other drugs that treat seizure disorders. Although its mechanism of action is not established, its activity may be related to increased brain levels of gamma-aminobutyric acid (GABA) or enhanced GABA action. It also may potentiate postsynaptic GABA responses, affect potassium channels, or have a direct membrane-stabilizing effect.

Lithium (Lithobid)

Lithium is indicated to treat bipolar disorder. The specific mechanism of action is unknown, but the drug alters sodium transport in nerve and muscle cells and influences reuptake of serotonin, norepinephrine, or both at cell membranes.