Narcissistic personality disorder

Individuals with narcissistic personality disorder may be grandiose or self-loathing, extraverted or socially isolated, captains of industry or unable to maintain steady employment, model citizens or prone to antisocial activities. NPD is complex and far from uniform in its presentation and consequences. Empirical evidence suggests several subtypes of NPD may exist (see the Subtypes section below), but in general, the disorder is known to have grandiose ("thick-skinned") and vulnerable ("thin-skinned") expressions. This behavior stems from low-self esteem, a need for admiration and validation, and social belonging (Mitra et al., 2024). While vulnerable-type patients typically show extreme distress and dysfunction, grandiose variants tend to be associated with greater psychological wellbeing, often manifesting dysfunction by occupational conflict, harming others, antisocial behavior or emotional strain resulting from perfectionism. While some evidence suggests that grandiose individuals show occasional reactive anger (a vulnerable trait), but narcissistically vulnerable individuals do not show signs of grandiosity, most studies show the vulnerable individuals show occasional bouts of grandiosity, narcissistically grandiose individuals show few or no signs of vulnerability. Other features NPD patients may have difficulty accepting help. They may also exhibit vengeful fantasies, as well as violent and antisocial behaviour. Patients with NPD have an impaired ability to recognize facial expressions or mimic emotions, as well as a lower capacity for emotional empathy and emotional intelligence but preserved capacity for cognitive empathy or an impaired theory of mind. People with NPD are less likely to engage in prosocial behavior. They can still act in selfless ways to improve others' perceptions of them, advance their social status, or if explicitly told to. Despite these characteristics, they are more likely to overestimate their capacity for empathy. Recent work, however, suggests narcissistic empathy deficits may be resolved (at least in part) by instructed perspective-taking. It is common for people with NPD to have difficult relationships. They may disrespect others' boundaries or idealize and devalue them. They commonly keep people emotionally distant, and project, deny, or split. NPD individuals manifesting vulnerability tend to become enraged when rejected or criticised, and may degrade, insult, or blame others who disagree with them. NPD may be associated with reduced insight into symptoms, especially in severe cases. However, work on lower levels of narcissism suggests such individuals are not only aware of their traits but see them in a positive light, and strive to maintain them over time. Given the high-function sociability associated with narcissism, some people with NPD might not view such a diagnosis as a functional impairment to their lives. Although overconfidence tends to make people with NPD very ambitious, such a mindset does not necessarily lead to professional high achievement and success, because they refuse to take risks, in order to avoid failure or the appearance of failure. Individuals with NPD often do not practice or believe in harm avoidance. Instead, they view punishment and accountability as inferior and unnecessary, and view consequences with a low regard, regardless of their negative behaviors and actions (Mitra et al., 2024). They have few social inhibitions due to their grandiose personality complex. Regarding novelty seeking, individuals contain an inherent pleasure to perform unusual gestures as an incentive to gain reward and extreme recognition for their gestures (Mitra et al., 2024). Attachment styles A meta-analysis of 33 studies examined the relationship between adult attachment styles, as conceptualized by Kim Bartholomew and Leonard M. Horowitz (1991) within attachment theory, and narcissistic traits. Results revealed weak positive correlations between narcissism and each insecure attachment style: anxious-preoccupied (r = 0.13), fearful-avoidant (r = 0.11), and dismissive-avoidant (r = 0.06). Vulnerable narcissism was positively associated with all three insecure attachment styles, with the strongest correlation for anxious-preoccupied (r = 0.43) and fearful-avoidant attachment (r = 0.31), and a weak association with dismissive-avoidant attachment (r = 0.15). In contrast, grandiose narcissism was not significantly associated with insecure attachment styles. A very weak but statistically significant positive association was observed with secure attachment (r = 0.06), indicating a negligible relationship overall. These findings suggest that grandiose narcissism may be largely independent of attachment-related processes and may instead be more strongly associated with other developmental factors, such as parental overvaluation. More recent research indicates that some domains of personality pathology may be largely independent of attachment processes. In particular, antagonistic traits (a central component of NPD, resembling the ICD-11 trait domain of Dissociality) appear to show limited overlap with attachment-related dimensions, suggesting that antagonism may not be strongly linked to attachment constructs. ==Causes==

Aetiology The cause of narcissistic personality disorder (NPD) is unclear, although there is evidence for a strong biological or genetic underpinning. It is unclear if or how much a person's upbringing contributes to the development of NPD, although many speculative theories have been proposed. Evidence to support social factors in the development of NPD is limited. A 2021 review concluded the most consistent finding among NPD patients is lowered gray matter volume in the medial prefrontal cortex, previously associated with self-enhancement tendencies. The results of a 2015 study associated the condition of NPD with a reduced volume of gray matter in the prefrontal cortex. It has been suggested that empathic dysfunction and selfish behaviour in NPD may result from dysfunction in the brain's salience network (SN; consisting of the anterior insula and cingulate cortices), which switches between internally- and externally-focused cognition, to inhibit the default mode network (DMN), involved in self-related information-processing, during social interactions resulting in continued self-focus even when interacting with distressed others. Consonantly, excessive selfishness in NPD appears to be related to decreased ability of the cingulate cortex to track motivational conflict between self-gain and other-pain. Grandiose and vulnerable expressions of NPD appear to relate differently to brain structure and function. Specifically, NPD patients with grandiose features show enhanced while those vulnerable features show reduced local efficiency in the DMN. Vulnerable cases of NPD also appear to show increased oxidative stress. Other aspects Evolutionary models of NPD have also been proposed. According to psychologist Marco Del Giudice, cluster B traits including NPD, predict increased mating success and fertility. NPD could potentially be an adaptive evolutionary phenomenon, though a risky one that can sometimes result in social rejection and failure to reproduce. Another proposal is that NPD may result from an excess of traits which are only adaptive in moderate amounts (leadership success increases with moderate degrees of narcissism, but declines at the high end of narcissism). Research on NPD is limited, because patients are hard to recruit for study. The cause of narcissistic personality disorder requires further research. ==Diagnosis==

A diagnosis of NPD, like other personality disorders, is made by a qualified healthcare professional in a clinical interview. Differential diagnosis is used in order to determine whether NPD is the most appropriate diagnosis (Mitra et al., (2024)). Classification Classification of personality disorders differs significantly between the two most prominent frameworks for classification of mental disorders, namely: the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, the most recent editions of which are the DSM-5-TR and ICD-11, respectively. While personality disorders, including NPD, are diagnosed as separate entities in the DSM-5; in the ICD-11 classification of personality disorders, they are assessed in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology. There is also a hybrid model, called the Alternative DSM-5 model for personality disorders, which defines NPD and five other PDs through disorder-specific combinations of pathological traits and areas of overall impairment. and criteria remaining the same as in the DSM-IV-TR. The categorical framework contains ten specific personality disorder categories, grouped into three clusters, with NPD belonging to cluster B, the disorders belonging to which often appear dramatic, emotional, or erratic. Having initially been developed as a replacement for the categorical model, the Alternative DSM-5 Model for Personality Disorders (AMPD) is located in Section III of both the DSM-5 and DSM-5-TR due to the replacement having been rejected. The AMPD defines six specific personality disorders – one of them being NPD – in terms of a description of the disorder; the characteristic manner in which the disorder impacts personality functioning, i.e. identity, self-direction, empathy and intimacy (criterion A); as well as a listing and description of the pathological personality traits associated with the disorder (criterion B). People diagnosed with NPD also experience significant levels of psychological distress, anxiety, and suicidal ideation because of its significant correlation with self-esteem (Gori & Topino, 2025). Also, perfectionism, fear, and shame have also been found to be associated with NPD. Over the past decade, narcissistic personality disorder has been a topic of high interest due to its multifaceted symptoms and factors associated with this personality disorder. As a result, in the field of psychology, the constant fluctuation of findings are urging mental health professionals to update and improve their therapeutic approach when treating their clients (Gori & Topino, 2025). Due to this disorder's complexity, further research and investigations are needed to provide professionals and the general public with credible data and useful approaches on how to work through treating this personality disorder. Network analysis is found to be an innovative application that can be applied to psychopathology, which is the study of mental illnesses and conditions. General personality impairment in individuals with NPD, as described in the AMPD, involves a fragile or exaggerated self-image that depends on others' approval, leading to unstable self-esteem. Their personal goals are often shaped by a need for recognition, with standards that are either unrealistically high or based on entitlement. They struggle to recognize others’ feelings unless directly relevant to themselves and often misjudge their own impact on others. Relationships are typically superficial, serving self-enhancement rather than mutual connection. At least two of these elements must have a "moderate or greater impairment". The AMPD lists the following pathological traits, both of which are required: grandiosity and attention-seeking; each of these is followed by a description of how the trait manifests in NPD. The AMPD specifiers allow for additional traits to be specified; it suggests additional antagonistic traits for "malignant", and traits of negative affectivity for "vulnerable" manifestations of NPD. Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder, while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested. Studies have shown that NPD corresponds well to the ICD-11 trait of Dissociality () Another PD comorbidity is paranoid personality disorder. The presence of BPD is also highly associated with traits such as grandiosity, lack of empathy, and praise-seeking behaviors which are characteristic of NPD. Research has shown that BPD has high comorbidity rates with NPD. Antisocial Personality Disorder is similarly characterized by impulsivity and a lack of empathy, but also by a disregard for the rights of others and a tendency to manipulate others. Additionally, both antisociality and narcissism are heavily correlated with psychopathy, further suggesting an overlap between the two. NPD should also be differentiated from mania and hypomania as these cases can also present with grandiosity, but present with different levels of functional impairment. Normalcy must also be ruled out; as is stated in the DSM-5: "Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting, and cause significant functional impairment or subjective distress, do they constitute narcissistic personality disorder." The person's manifested personality traits must substantially differ from social norms. ==Subtypes==

Although the DSM-5 diagnostic criteria for NPD has been viewed as homogeneous, there are a variety of subtypes used for classification of NPD. There is poor consensus on how many subtypes exist, but there is broad acceptance that there are at least two: grandiose or overt narcissism, and vulnerable or covert narcissism. which can be distinguished by symptom criteria, comorbidity and other clinical criteria. These are as follows: Grandiose/overt: the group exhibits grandiosity, entitlement, interpersonal exploitativeness and manipulation, pursuit of power and control, lack of empathy and remorse, and marked irritability and hostility. This group was noted for high levels of comorbid antisocial and paranoid personality disorders, substance abuse, externalizing, unemployment and greater likelihood of violence. Vulnerable narcissism is sometimes comorbid with diagnoses of avoidant, borderline and dependent personality disorders. The first was the "oblivious" subtype of narcissist, equivalent to the grandiose subtype. This group was described as being grandiose, arrogant and thick-skinned, while also exhibiting personality traits of helplessness and emotional emptiness, low self-esteem and shame. These were observed in people with NPD to be expressed as socially avoidant behavior in situations where self-presentation is difficult or impossible, leading to withdrawal from situations where social approval is not given. The second subtype Gabbard described was termed "hypervigilant", equivalent to the vulnerable subtype. People with this subtype of NPD were described as having easily hurt feelings, an oversensitive temperament, and persistent feelings of shame. Communal narcissism: A fourth type is the communal narcissist. Communal narcissism is a form of narcissism that occurs in group settings. It is characterized by an inflated sense of importance and a need for admiration from others. In relation to the grandiose narcissist, a communal narcissist is arrogant and self-motivating, and shares the sense of entitlement and grandiosity. However, the communal narcissist seeks power and admiration in the communal realm. They see themselves as altruistic, saintly, caring, helpful, and warm. Individuals who display communal narcissism often seek out positions of power and influence within their groups. Millon's subtypes In the study Disorders of Personality: DSM-IV-TM and Beyond (1996), Theodore Millon suggested five subtypes of NPD, although he did not identify specific treatments per subtype. Masterson's subtypes (exhibitionist and closet) In 1993, James F. Masterson proposed two subtypes for pathological narcissism, exhibitionist and closet. Both fail to adequately develop an age- and phase- appropriate self because of defects in the quality of psychological nurturing provided, usually by the mother. A person with exhibitionist narcissism is similar to NPD described in the DSM-IV and differs from closet narcissism in several ways. A person with closet narcissism is more likely to be described as having a deflated, inadequate self-perception and greater awareness of emptiness within. A person with exhibitionist narcissism would be described as having an inflated, grandiose self-perception with little or no conscious awareness of feelings of emptiness. Such a person would assume that their condition was normal and that others were just like them. A person with closet narcissism is described to seek constant approval from others and appears similar to those with borderline personality disorder in the need to please others. A person with exhibitionist narcissism seeks perfect admiration all the time from others. is a syndrome consisting of a combination of NPD, antisocial personality disorder, and paranoid traits. A person with malignant narcissism was described as deriving higher levels of psychological gratification from accomplishments over time, suspected to worsen the disorder. Because a person with malignant narcissism becomes more involved in psychological gratification, it was suspected to be a risk factor for developing antisocial, paranoid, and schizoid personality disorders. The term malignant is added to the term narcissist to indicate that individuals with this disorder have a severe form of narcissistic disorder that is characterized also by features of paranoia, psychopathy (anti-social behaviors), aggression, and sadism. Historical demarcation of grandiose and vulnerable types Over the years, many clinicians and theorists have described two variants of NPD akin to the grandiose and vulnerable expressions of trait narcissism. Some examples include: ==Assessment and screening==

Narcissistic Personality Inventory Risk factors for NPD and grandiose/overt and vulnerable/covert subtypes are measured using the narcissistic personality inventory, an assessment tool originally developed in 1979, which has undergone multiple iterations with new versions in 1984, 2006 and 2014. It captures principally grandiose narcissism, but also seems to capture elements of vulnerability. A popular three-factor model has it that grandiose narcissism is assessed via the Leadership/Authority and Grandiose/Exhibitionism facets, while a combination of grandiose and vulnerable traits are indexed by the Entitlement/Exploitativeness facet. Pathological Narcissism Inventory The Pathological Narcissism Inventory (PNI) was designed to measure fluctuations in grandiose and vulnerable narcissistic states, similar to what is ostensibly observed by some clinicians (though empirical demonstration of this phenomenon is lacking). While having both "grandiosity" and vulnerability scales, empirically both seem to primarily capture vulnerable narcissism. The PNI scales show significant associations with parasuicidal behavior, suicide attempts, homicidal ideation, and several aspects of psychotherapy utilization. Five-Factor Narcissism Inventory In 2013, the Five-Factor Narcissism Inventory (FFNI) was defined as a comprehensive assay of grandiose and vulnerable expressions of trait narcissism. The scale measures 11 traits of grandiose narcissism and 4 traits of vulnerable narcissism, both of which correlate with clinical ratings of NPD (with grandiose features of arrogance, grandiose fantasies, manipulativeness, entitlement and exploitativeness showing stronger relations). Later analysis revealed that the FFNI actually measures three factors: • Agentic Extraversion: an exaggerated sense of self-importance, grandiose fantasies, striving for greatness and acclaim, social dominance and authoritativeness, and exhibitionistic, charming interpersonal conduct. • Self-Centred Antagonism: disdain for others, psychological entitlement, interpersonally exploitative and manipulative behaviour, lack of empathy, anger in response to criticism or rebuke, suspiciousness, and thrill-seeking. • Narcissistic Neuroticism: shame-proneness, oversensitivity and negative emotionality to criticism and rebuke, and excessive need for admiration to maintain self-esteem. Grandiose narcissism is a combination of agency and antagonism, and vulnerability is a combination of antagonism and neuroticism. The three factors show differential associations with clinically important variables. Agentic traits are associated with high self-esteem, positive view of others and the future, autonomous and authentic living, commitment to personal growth, sense of purpose in life and life satisfaction. Neurotic traits show precisely the opposite correlation with all of these variables, while antagonistic traits show more complex associations; they are associated with negative view of others (but not necessarily of the self), a sense of alienation from their 'true self', disinterest in personal growth, negative relationships with others, and all forms of aggression. Millon Clinical Multiaxial Inventory The Millon Clinical Multiaxial Inventory (MCMI) is another diagnostic test developed by Theodore Millon. The MCMI includes a scale for narcissism. The NPI and MCMI have been found to be well correlated. Whereas the MCMI measures narcissistic personality disorder (NPD), the NPI measures narcissism as it occurs in the general population; the MCMI is a screening tool. In other words, the NPI measures "normal" narcissism; i.e., most people who score very high on the NPI do not have NPD. Indeed, the NPI does not capture any sort of narcissism taxon as would be expected if it measured NPD. A 2020 study found that females scored significantly higher on vulnerable narcissism than males, but no gender differences were found for grandiose narcissism. ==Management==

Treatment for NPD is primarily psychotherapeutic; there is no clear evidence that psychopharmacological treatment is effective for NPD, although it can prove useful for treating comorbid disorders. Psychotherapeutic treatment falls into two general categories: psychoanalytic/psychodynamic and cognitive behavioral. Psychoanalytic therapies include schema therapy, transference focused psychotherapy, mentalization-based treatment and metacognitive psychotherapy. Cognitive behavioral therapies include cognitive behavioral therapy and dialectal behavior therapy. Formats also include group therapy and couples therapy. Management of narcissistic personality disorder has not been well studied, however many treatments tailored to NPD exist. NPD is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they often express seeking relief from a comorbid mental disorder, including major depressive disorder, a substance use disorder (drug addiction), or bipolar disorder. ==Prognosis==

, no treatment guidelines exist for NPD and no empirical studies have been conducted on specific NPD groups to determine efficacy for psychotherapies and pharmacology. ==Epidemiology==

, overall prevalence is estimated to range from 0.8% to 6.2%. In 2008 under the DSM-IV, lifetime prevalence of NPD was estimated to be 6.2%, with 7.7% for men and 4.8% for women, with a 2015 study confirming the gender difference. In clinical settings, prevalence estimates range from 1% to 15%. The same 2008 study presented a significantly higher prevalence of NPD among Black men and women and Hispanic women, younger adults, and separated/divorced/widowed and never married adults. People with a fragile variant of NPD (see Subtypes) are prone to bouts of psychological depression, often to the degree that meets the clinical criteria for a co-occurring depressive disorder. NPD is associated with the occurrence of bipolar disorder and substance use disorders, especially cocaine use disorder. ==History==

The term "narcissism" comes from the first century (written in the year 8 AD) narrative poem the Metamorphoses by the Roman poet Ovid. Book III of the Metamorphoses features a myth about two main characters, Narcissus and Echo. Narcissus is a handsome young man who spurns the advances of many potential lovers. When Narcissus rejects Echo, a nymph cursed to only echo the sounds that others made, the goddess Nemesis punishes him by making him fall in love with his own reflection in a pool of water. When Narcissus discovers that the object of his love cannot love him back, he slowly pines away and dies. The concept of excessive selfishness has been recognized throughout history. In ancient Greece, the concept was understood as hubris. It is only since the late 1800s that narcissism has been defined in psychological terms: • Havelock Ellis (1898) was the first psychologist to use the term when he linked the myth to the condition in one of his patients. The term narcissistic personality disorder (NPD) was coined by Heinz Kohut in 1968. Waelder's initial study has been influential in the way narcissism and the clinical disorder Narcissistic personality disorder are defined today Freudianism and psychoanalysis Much of the early history of narcissism and NPD originates from psychoanalysis. Regarding the adult neurotic's sense of omnipotence, Sigmund Freud said that "this belief is a frank acknowledgement of a relic of the old megalomania of infancy"; and concluded that: "we can detect an element of megalomania in most other forms of paranoic disorder. We are justified in assuming that this megalomania is essentially of an infantile nature, and that, as development proceeds, it is sacrificed to social considerations." Narcissistic injury and narcissistic scar are terms used by Freud in the 1920s. Narcissistic wound and narcissistic blow are other, almost interchangeable, terms. When wounded in the ego, either by a real or a perceived criticism, a narcissistic person's displays of anger can be disproportionate to the nature of the criticism suffered; a condition later reactivated in adult life, if the individual takes up gambling. In The Psychoanalytic Theory of Neurosis (1946), Otto Fenichel said that people who, in their later lives, respond with denial to their own narcissistic injury usually undergo a similar regression to the megalomania of childhood. Narcissistic supply Narcissistic supply was a concept introduced by Otto Fenichel in 1938, to describe a type of admiration, interpersonal support, or sustenance drawn by an individual from his or her environment and essential to their self-esteem. The term is typically used in a negative sense, describing a pathological or excessive need for attention or admiration that does not take into account the feelings, opinions, or preferences of other people. Narcissistic rage The term narcissistic rage was a concept introduced by Heinz Kohut in 1972. Narcissistic rage was theorised as a reaction to a perceived threat to a narcissist's self-esteem or self-worth. Narcissistic rage occurs on a continuum from aloofness, to expressions of mild irritation or annoyance, to serious outbursts, including violent attacks. Aggression have been found to be highly correlated to personality disorders (PD), pathological narcissism, (PN) narcissistic personality disorder (NPD), and even borderline personality disorder (Théberge & Gamache, 2023). Narcissistic rage reactions are not necessarily limited to narcissistic personality disorder. They may also be seen in catatonic, paranoid delusion, and depressive episodes. This Kleinian therapeutic approach built upon Heinz Kohut's view of narcissistic megalomania as an aspect of normal mental development, by contrast with Otto Kernberg's consideration of such grandiosity as a pathological distortion of normal psychological development. The merging of the terms "inflated self-concept" and "actual self" is evident in later research on the grandiosity component of narcissistic personality disorder, along with incorporating the defence mechanisms of idealization and devaluation and of denial. Modern diagnosis In the ICD-10 classification of personality disorders, previous to the newer ICD-11, narcissistic personality disorder is listed under the category of other specific personality disorders (), meaning the ICD-10 required that cases otherwise described as NPD in the DSM-5 would only need to meet a general set of diagnostic criteria. The extent of controversy about narcissism was on display when the committee on personality disorders for the 5th Edition (2013) of the Diagnostic and Statistical Manual of Mental Disorders recommended the removal of Narcissistic Personality from the manual. A contentious three-year debate unfolded in the clinical community with one of the sharpest critics being John Gunderson, who led the DSM personality disorders committee for the 4th edition of the manual. The American Psychiatric Association's (APA) formulation, description, and definition of narcissistic personality disorder, as published in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed., Text Revision (DSM-IV-TR, 2000), was criticised by clinicians as inadequately describing the range and complexity of the personality disorder that is NPD. That it is excessively focused upon "the narcissistic individual's external, symptomatic, or social interpersonal patterns – at the expense of ... internal complexity and individual suffering", which reduced the clinical utility of the NPD definition in the DSM-IV-TR. Clinicians critical of the DSM-5 revision characterized the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist", which is of limited usefulness in clinical practice. Despite the reintroduction of the NPD entry, the APA's re-formulation, re-description, and re-definition of NPD, towards a dimensional view based upon personality traits, remains in the list of personality disorders of the DSM-5. ==Controversy==

A 2011 study concluded that narcissism should be conceived as personality dimensions pertinent to the full range of personality disorders, rather than as a distinct diagnostic category. In a 2012 literature review about NPD, the researchers concluded that narcissistic personality disorder "shows nosological inconsistency, and that its consideration as a trait domain needed further research would be strongly beneficial to the field." ==In popular culture==

• Suzanne Stone-Maretto, Nicole Kidman's character in the film To Die For (1995), wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she "was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder... had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder". • Jay Gatsby, the eponymous character of F. Scott Fitzgerald's novel The Great Gatsby (1925), "an archetype of self-made American men seeking to join high society", has been described by English professor Giles Mitchell as a "pathological narcissist" for whom the "ego-ideal" has become "inflated and destructive" and whose "grandiose lies, poor sense of reality, sense of entitlement, and exploitive treatment of others" conspire toward his own demise. ==See also==