Narcissistic personality disorder (NPD) is a complex and heterogeneous personality disorder characterized by patterns of grandiosity, entitlement, low empathy, and interpersonal difficulties, which can manifest as either grandiose ("thick-skinned") or vulnerable ("thin-skinned") forms. Grandiose individuals display arrogance, social dominance, and exploitative behaviors, while vulnerable individuals show shame, inferiority, hypersensitivity, and extreme reactions to criticism. NPD often involves impaired emotional empathy, superficial relationships, and difficulty tolerating disagreement. It is often co-morbid with other mental disorders and associated with significant functional impairment and psychosocial disability.
There are two definitions of NPD in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM); whereas the primary definition is categorical and stems from previous DSM editions, the other definition – part of the Alternative DSM-5 model for personality disorders – is based on dimensional measures of severity of the disorder as well as on specific pathological traits. The International Classification of Diseases (ICD) defines only a general personality disorder since the introduction of the latest edition; hence, it does not include an NPD category.
There is no standard treatment for NPD. Its high comorbidity with other mental disorders influences treatment and outcomes. Psychotherapeutic treatments generally fall into two categories: psychoanalytic/psychodynamic and cognitive behavioral therapy, with growing support for integration of different modalities in therapy. However, there are few studies on the effectiveness of treatments. Treatment is frequently not sought; one's subjective experience of the mental disorder, as well as one's agreement to and level of engagement with treatment, are highly dependent on one's motivation to change.
NPD's etiology is thought to be largely genetic and neurobiological, with structural and functional brain differences in areas related to self-processing and empathy. Assessment tools such as the Narcissistic Personality Inventory or Pathological Narcissism Inventory can help differentiate subtypes. NPD has historical roots in psychoanalytic theory and remains a subject of controversy in psychiatric classification, while its manifestations continue to appear in literature and media as exemplars of extreme self-focus and entitlement.
Signs and symptoms
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.
Grandiose, thick-skinned NPD patients show a sense of uniqueness or superiority, attitudes of entitlement, a belief that others envy their abilities or status, low empathy, social dominance, superficial charm, disdainfulness or snobbery, and an exploitative interpersonal style characterized by manipulation and selfishness.
Vulnerable, thin-skinned individuals with NPD also show entitlement, selfishness and low empathy, but uniquely, they demonstrate feelings of shame and inferiority, are envious of others' abilities or status, tend to be shy, paranoid, vindictive, and emotionally dependent on admiration, and show extreme rage and hostility in response to rejection and criticism. This behavior stems from low self-esteem, a need for admiration and validation, and social belonging.
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.Miller, J. D., Campbell, W. K., & Pilkonis, P. A. (2007). Narcissistic personality disorder: Relations with distress and functional impairment. Comprehensive psychiatry, 48(2), 170-177.
It is often theorized that some patients may oscillate between grandiosity and vulnerability.Gore, W. L., & Widiger, T. A. (2016). Fluctuation between grandiose and vulnerable narcissism. Personality Disorders: Theory, Research, and Treatment, 7(4), 363. While some evidence suggests that grandiose individuals show occasional reactive anger (a vulnerable trait), but narcissistically vulnerable individuals do not show signs of grandiosity,Edershile, E. A., & Wright, A. G. (2021). Fluctuations in grandiose and vulnerable narcissistic states: A momentary perspective. Journal of Personality and Social Psychology, 120(5), 1386. most studies show the vulnerable individuals show occasional bouts of grandiosity, narcissistically grandiose individuals show few or no signs of vulnerability.Edershile, E. A., Oltmanns, J. R., Widiger, T. A., & Wright, A. G. (2021). Predicting fluctuation in narcissistic states: An examination of the g-FLUX scale. Psychological assessment, 33(1), 60.Oltmanns, J. R., & Widiger, T. A. (2018). Assessment of fluctuation between grandiose and vulnerable narcissism: Development and initial validation of the FLUX scales. Psychological Assessment, 30(12), 1612.Henttonen, P., Salmi, J., Peräkylä, A., & Krusemark, E. A. (2022). Grandiosity, vulnerability, and narcissistic fluctuation: Examining reliability, measurement invariance, and construct validity of four brief narcissism measures. Frontiers in psychology, 13, 993663.
Other features NPD patients may have difficulty accepting help. They may also exhibit vengeful fantasies, as well as violent and antisocial behaviour. They are more likely to try forms of plastic surgery due to a desire to gain attention and to be seen as beautiful.
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. 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.
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. 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 may refuse to take risks, in order to avoid failure or the appearance of failure. Moreover, the psychological inability to tolerate disagreement, contradiction, and criticism makes it difficult for persons with NPD to work cooperatively or to maintain long-term relationships.
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. 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.
Causes 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. Research on NPD is limited, because patients are hard to recruit for study.
Evidence to support social factors in the development of NPD is limited. Some studies have found NPD correlates with permissive and overindulgent parenting in childhood. Others have found correlations with harsh discipline, neglect or abuse. Findings have been inconsistent, and scientists do not know if these correlations are causal, as these studies do not control for genetic confounding.
This problem of genetic confounding is explained by psychologist Svenn Torgersen in a 2009 review:
Twin studies allow scientists to assess the influence of genes and environment, in particular, how much of the variation in a trait is attributed to the "shared environment" (influences shared by twins, such as parents and upbringing) or the "unshared environment" (measurement error, noise, differing illnesses between twins, randomness in brain growth, and social or non-social experiences that only one twin experienced). According to a 2018 review, twin studies of NPD have found little or no influence from the shared environment, and a major contribution of genes and the non-shared environment:
According to neurogeneticist Kevin Mitchell, a lack of influence from the shared environment indicates that the non-shared environmental influence may be largely non-social, perhaps reflecting innate processes such as randomness in brain growth.
Pathophysiology Neuroscientists have also studied the brains of people with NPD using structural imaging technology. 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. Studies of the occurrence of narcissistic personality disorder identified structural abnormalities in the brains of people with NPD, specifically, a lesser volume of gray matter in the left, anterior insular cortex. 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.Jankowiak-Siuda, K., & Zajkowski, W. (2013). A neural model of mechanisms of empathy deficits in narcissism. Medical science monitor: international medical journal of experimental and clinical research, 19, 934. 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.Stolz, D. S., Vater, A., Schott, B. H., Roepke, S., Paulus, F. M., & Krach, S. (2021). Reduced frontal cortical tracking of conflict between self-beneficial versus prosocial motives in Narcissistic Personality Disorder. NeuroImage: Clinical, 32, 102800.
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 with vulnerable features show reduced local efficiency in the DMN.Cao, C., Lou, J., & Liu, W. (2022). Local inefficiency of the default mode network in young men with narcissistic personality disorder. Neuroscience Letters, 784, 136720. Vulnerable cases of NPD also appear to show increased oxidative stress.
Other aspects