Narcissistic personality disorder

by | Mental Health

Narcissistic personality disorder (NPD) is best described as a paradox. People with NPD may act superior and confident, but are often fragile and lack self-esteem. They crave attention and praise yet are unable to form close relationships. NPD causes great distress to both the person with the disorder and those around them.

The facts

  • NPD affects more men than women: 50%–75% of people diagnosed worldwide are men.
  • NPD is an old, established diagnosis: narcissism has been referenced in psychological literature since 1911 and NPD was first listed in the Diagnostic & Statistical Manual (DSM) in 1980.
  • NPD is sometimes called pathological narcissism, but it’s different to narcissistic personality type, which is not a disorder.

The myths

  • Myth: NPD is the same as acting narcissistic
  • Reality: Acting narcissistic is part of the human condition. NPD is classed as a disorder because it is marked by extreme narcissistic symptoms.
  • Myth: NPD is common – there’s an NPD epidemic
  • Reality: NPD isn’t common. It only affects between 0.5% and 1% of the general population.
  • Myth: I’m pretty sure [insert name of famous person] has NPD.
  • Reality: It’s incredibly dangerous to diagnose at a distance. It’s also ineffective. Just because someone appears to behave in a narcissistic way, it doesn’t mean they have NPD (or any mental illness, for that matter).
  • Myth: People with NPD are bad/evil
  • Reality: People with NPD live with a complex mental illness. Their behaviour can make life hard for them and the people around them, but it’s a symptom of a mental illness, not a moral failing.


There are nine key symptoms associated with NPD. To be diagnosed with NPD, a person must be assessed by a medical professional to be experiencing least five of the following:

  • A grandiose sense of self-importance.
  • Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  • A belief that they are ‘special’ and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
  • An intense need for excessive admiration.
  • A sense of entitlement – that they should get and have whatever they want.
  • A tendency to be interpersonally exploitative – in that they use others to achieve their own ends.
  • A lack of empathy, demonstrated through an unwillingness to recognise or identify with the feelings and needs of others.
  • Envy of others, or the belief that others are envious of them.
  • Arrogant, haughty or supercilious behaviour and attitudes.

There’s criticism that this clinical set of symptoms concentrates too much on how people with NPD relate to others, and not enough on internal symptoms, including:

  • low self-esteem
  • harsh self-criticism
  • overriding insecurity
  • feelings of inferiority
  • loneliness and isolation
  • hypersensitivity
  • fear, rage, shame and vulnerability.

Narcissism vs narcissistic personality type vs NPD

Narcissism is the human experience of feeling important, needing admiration and attention, wanting success and love. It’s normal and can even be a healthy personality trait, if it’s mild and occasional. It’s perfectly possible to feel or act a little narcissistic, even unpleasantly so, without having what would be classed as a disorder.

A person whose personality is strongly characterised by narcissistic traits may act obnoxious and difficult, but still not have a disorder.

Think of NPD as narcissistic personality traits taken to extremes: looking excessively to others for praise, feeling exceptional and superior, having low empathy, craving attention and having only superficial relationships.

NPD  is an extreme form of narcissism that can cause great distress and functional impairment, and last a long time.


The exact causes of NPD are unknown. Because NPD can be inherited, a genetic link is suspected. There are also theories that excessive praise or judgment by parents, early trauma and abuse may contribute to NPD.

NPD is not caused by a medical condition, drugs, or a person’s developmental stage in life.

Seeking help, diagnosis & treatment

Because NPD often causes feelings of superiority, entitlement and arrogance, people living with the disorder don’t always recognise that they have a mental illness or seek help – even when their patterns of behaviour cause serious problems in their lives and the lives of those around them.

For those who do seek help, diagnosis is made by a mental health professional and treatment generally takes the form of psychological therapies, including:

  • Psychodynamic therapy: used to explore and reduce pain from past events.
  • Cognitive behavioural therapy (CBT): used to interrupt and change unhelpful patterns of thinking or behaviour that are behind people’s difficulties.
  • Relationship therapy: used to resolve conflicts in couples or families and improve communication and problem-solving.

Therapy for NPD can be long-term. Its success depends on the willingness of the person with NPD to both acknowledge their disorder and commit to change.

NPD is not treated with medication, although medications may be prescribed for associated depression, anxiety or other health issues.

Caring for someone with NPD

People with NPD tend to be self-obsessed, believing others are the problem, so many see no reason to attend counselling. They can interpret encouragement to seek help as criticism, and respond very defensively, deflecting fault onto others.

A useful technique to encourage therapy is suggesting that a shared problem or issue exists, focussing on things you both can work through.

Self-care for family, friends & carers

People living with NPD can be very difficult to relate to and sympathise with. They frequently act in hurtful ways towards the people around them.

Supportive therapy is a good way for friends and carers to build strategies for coping with a loved one’s behaviour, rebuilding self-esteem and setting boundaries.

Other self-help strategies include:

  • Spending time with people who provide an honest reflection of who you are
  • Participating in meaningful activities that make you feel good.
  • Following through with boundaries you set. Backing down sends the message you don’t need to be taken seriously.
  • Accepting that you cannot change your loved one.
  • Understanding their behaviour is a reflection of their insecurities, not of you.