ADHD Comorbidities & Related Conditions

What is Narcissistic Personality Disorder? NPD Symptoms, Types, Causes & Treatments

Narcissistic personality disorder (NPD) symptoms include arrogance, entitlement, and envy. Here, understand this Cluster B personality disorder — its signs, types, causes, and treatments.

Woman with ADHD looking at herself in a mirror, learning to quiet her inner bully critic

What Is Narcissistic Personality Disorder?

Narcissistic Personality Disorder (NPD) is a condition marked by a pattern of grandiosity, fixation on power fantasies, desire for admiration, arrogance, lack of empathy, and envy. Individuals with NPD may be overly sensitive to criticism, though they may hide their fragile self-esteem behind a self-important exterior.

NPD is estimated to be the second most prevalent personality disorder, affecting about 6.2% of the population1. It is one of ten personality disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Along with histrionic, antisocial, and borderline personality disorders, NPD is a Cluster B disorder, which causes affected individuals to appear erratic, emotional, or dramatic.

Narcissistic Personality Disorder: Symptoms

Though symptoms may manifest in different ways, people with NPD experience at least five of the following2:

  • Inflated sense of self importance
  • Preoccupation with fantasies of power, beauty, or ideal love
  • Belief that he or she is unique and should only associate with other special or high-status people and institutions
  • Requires admiration
  • Unreasonable entitlement
  • Takes advantage of others
  • Lacks empathy
  • Envious of others, or believes that others are envious of them
  • Arrogant behaviors or attitudes

[Self-Test: Borderline Personality Disorder]

Narcissistic Personality Disorder: Other Signs

Though the DSM symptoms are used to diagnose NPD, the following associated features may help clinicians support a diagnosis. These can include3:

  • Low self-esteem. Despite their outwardly arrogant presentation, people with NPD often have low self-esteem. They are vulnerable to injuries to their egos and may become angry or humiliated.
  • Unwillingness to engage in potentially humiliating tasks. Because of their low self-esteem, people with NPD are hesitant to publicly struggle.
  • Eating disorders. Because some people with NPD rely on external validation, they are susceptible to developing eating disorders to increase their perceived self-worth4.
  • Substance abuse. Though there is an established link between substance use disorder and NPD, there is no consensus on a specific cause. There are likely varied reasons that people with NPD develop substance use disorders.

Grandiose vs. Vulnerable Narcissism

Though both the DSM-5 and popular ideas of narcissism center on open arrogance, NPD researchers identify two different subgroups: grandiose and vulnerable.

Grandiose narcissism is the familiar self-important expression of narcissism. Grandiose narcissists will be more likely to display egocentric traits such as:

  • Entitlement
  • Manipulation of others
  • Overt arrogance
  • Aggression
  • Anger/Rage

Vulnerable narcissism is a less understood aspect of narcissism, but one that research is beginning to consider. Vulnerable narcissism is also often called covert narcissism, as many of the symptoms are not readily visible to outside observers. Vulnerable narcissists do not have a grandiose self-esteem, and as such are sensitive to rejection or criticism. Though vulnerable narcissists do still have grandiose fantasies and believe they are somehow “special,” they display different symptoms, such as:

  • Shyness
  • Shame
  • Few meaningful relationships due to fear of rejection
  • Hyper-vigilance
  • Need for outside approval
  • Low self-esteem5

[Self-Test: Borderline Personality Disorder]

Causes of NPD

As with all personality disorders, the causes of NPD are opaque. However, a Norwegian study on twins found that genetics only accounted for 25% of the variation in NPD presence, while environmental factors were responsible for 75%6.

Environmental causes of NPD may include parenting styles, generational differences, and even economic factors7.

Treating NPD

NPD grandiosity and resistance to perceived criticisms can make treating NPD uniquely difficult. Patients with NPD have a higher rate of treatment non-adherence and dropout. In addition, there are no clinical guidelines or empirical studies on the best treatments for NPD. In many cases, therapies designed for borderline personality disorder will be modified to meet the needs of people with NPD. These therapies may include8:

  • Mentalization based therapy
  • Transference-focused psychotherapy
  • Schema focused psychotherapy

There are no medications approved to treat NPD, however medications may be prescribed for co-occurring mood or anxiety disorders.

Narcissistic Personality Disorder: Next Steps

View Article Sources

1Sansone, R. A., & Sansone, L. A. (2011). Personality disorders: a nation-based perspective on prevalence. Innovations in clinical neuroscience, 8(4), 13–18.
2American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 669,670 https://doi.org/10.1176/appi.books.9780890425596
3American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 671 https://doi.org/10.1176/appi.books.9780890425596
4Sivanathan, D., Bizumic, B., Rieger, E. et al. Vulnerable narcissism as a mediator of the relationship between perceived parental invalidation and eating disorder pathology. Eat Weight Disord 24, 1071–1077 (2019). https://doi.org/10.1007/s40519-019-00647-2
5Nicole M. Cain, Aaron L. Pincus, et al. Narcissism at the crossroads: Phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis, Clinical Psychology Review, Volume 28, Issue 4, 2008, Pages 638-656, https://doi.org/10.1016/j.cpr.2007.09.006.
6Kendler, K. S., Aggen, S. H., et al. (2008). The structure of genetic and environmental risk factors for DSM-IV personality disorders: a multivariate twin study. Archives of general psychiatry, 65(12), 1438–1446. https://doi.org/10.1001/archpsyc.65.12.1438
7Causes and Development of Narcissism. In: Hermann, A., Brunell, A., Foster, J. (eds) Handbook of Trait Narcissism. https://doi.org/10.1007/978-3-319-92171-6_16
8Narcissistic Personality Disorder: Diagnostic and Clinical Challenges, Eve Caligor, Kenneth N. Levy, and Frank E. Yeomans, American Journal of Psychiatry 2015 172:5, https://doi.org/10.1176/appi.ajp.2014.14060723


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