The Greek god Narcissus was known for his beauty. He was so enamored of his own appearance that he spent much of his life gazing at his visage in a pool of water. He was contemptuous of those who loved him, causing some to end their own lives in an attempt to prove their devotion. His story is a cautionary tale about the catastrophic effects of excessive self-love. People with narcissism or narcissistic personality disorder display traits similar to those of Narcissus.
Narcissism is excessive self-involvement that causes a person to ignore the needs of others. Almost everyone occasionally engages in narcissistic behavior. People with narcissistic personality disorder (NPD) have personalities characterized by intense self-involvement and chronic disregard for others.
People with NPD rarely seek therapy. This is because people with NPD may neither notice nor care about the effects of their narcissism on others. The right therapist, however, can help people with NPD understand the harmful effects of narcissism, including to themselves. Therapy can help a person with NPD understand and prioritize the needs of others, repair broken relationships, and cultivate empathy.
Prevalence estimates of narcissism vary and may not be reliable. This is because few people with NPD seek treatment. Even when they do, they may not readily admit to narcissistic symptoms or personality traits. For this reason, NPD remains poorly understood and is not well-studied.
A 2008 study puts the lifetime prevalence rate of NPD at 6.2%. A 2010 analysis of seven previous studies found an average prevalence of 1.06%, and a prevalence range of 0%-6.2%.
Narcissism is more common in men than in women. Research published in 2008 suggests a lifetime rate of NPD among men of 7.7% compared to 4.8% among women.
A 2015 meta-analysis found that men score higher than women on measures of narcissism like leadership/authority and exploitative/entitlement. However, the authors of that study found no differences between men and women on measures of vulnerable narcissism. This less-studied form of narcissism is characterized by hypersensitivity to rejection.
People with narcissism, sometimes referred to pointedly as “narcissists,” are excessively fixated on their own needs, while simultaneously obsessed with gaining approval from others. Their relationships with others are superficial, designed as a source of admiration rather than a channel for mutual intimacy. They may engage in narcissistic abuse, either using someone as a tool to feed their ego or neglecting the needs of someone who depends on them.
The DSM-5 radically overhauled the previous DSM-IV diagnostic criteria for NPD. Under the new guidelines, to qualify for a personality disorder diagnosis, a person must have:
- Significant impairments in their sense of self and interpersonal life.
- A personality dominated by one or more harmful traits.
- Impairments in personality that are stable over time and which appear across many contexts.
- Impairments that are not better described by the person’s environment, developmental stage, or substance abuse.
The characteristics of NPD include:
- Obsessive interest in the perception of others; a person may rely on admiration and high regard as their sole source of self-esteem.
- A grossly inflated sense of self. Some people may vacillate between very high or very low self-esteem, or experience low self-esteem when they don’t get sufficient admiration.
- Excessive self-involvement that undermines the ability to empathize with the feelings of others.
- Disregard for the needs of others.
- A sense of entitlement.
- Attention-seeking behavior designed to gain admiration.
These broad categories of behavior may cause a narcissistic person to display many of the following narcissism symptoms:
- Preoccupation with fantasies of extreme success, power, or fame.
- Constant need for admiration and affirmation.
- A strong sense of entitlement.
- Envy of others, particularly their achievements, or belief that others should envy them.
- Inflated sense of self-esteem; megalomaniacal tendencies.
- Belief that they are special or unique.
- Setting unrealistic goals.
- Exploitation of others.
- Difficulty maintaining healthy relationships.
- Lack of empathy or ability to take responsibility for behaviors.
- Cannot tolerate criticism.
A 2015 American Journal of Psychiatry review criticizes the DSM-5 for a limited definition that fails to fully capture the diverse array of traits people with NPD display. Drawing upon previous research, that study points to four distinct sub-types of NPD:
- High-functioning: This characterizes people who are able to garner enough admiration to fulfill their narcissistic needs. They are often highly successful and admired.
- Middle-functioning: This sub-type includes people with a grandiose sense of importance who may struggle interpersonally, especially if their jobs do not satisfy their need for admiration.
Members of these two categories rarely seek treatment, unless the loss of a job, loved one, or financial well-being threatens their sense of self.
Two other sub-types struggle more with daily functioning and are more likely to seek treatment:
- Malignant narcissists: In addition to traditional NPD traits, people with “malignant” traits also display antisocial traits. They may be paranoid, aggressive, or sadistic. They can be difficult to treat because they may intimidate clinicians.
- People with co-morbid borderline traits: Many people with borderline personality struggle to have a coherent sense of self. When borderline personality co-occurs with NPD, a person may alternate between grandiosity and suicidal gestures.
In the popular imagination, a narcissist is a self-centered egotist who constantly seeks admiration. Narcissistic traits, however, exist on a continuum. They range from subtle to dramatic and can vary with context. Some examples of the continuum of narcissistic traits include:
- Entitlement: A person with a sense of entitlement may trample the rights of others to get what they believe is rightfully theirs. This can manifest in subtle ways, such as routinely cheating on tests, or in more dramatic ways, such as stealing.
- Attention-seeking: A person with NPD craves attention and admiration. To get it, they might become a perfectionist and excel at their job. They might occupy a position of power that offers much attention. Or they may adopt attention-seeking behaviors, such as becoming angry or withdrawn when they don’t get what they want.
- Self-involvement: Self-involvement does not necessarily mean selfishness. A person with NPD may appear quite giving and caring when it serves their needs or gets them the admiration they crave. Self-involvement can also manifest as intense preoccupation with one’s own needs at the expense of other people. For example, a narcissistic mother might spend all her time seeking attention from people she respects while neglecting her child. People with NPD often struggle to empathize with or manage the needs of their children and family.
- Approval-seeking: A person with NPD may continuously try to curry favor from a person they perceive to be powerful or important, such as a boss or politician. They may do this while neglecting the needs and rights of people they see as less important, such as their children or coworkers.
NPD can change a person’s perceptions of what’s normal and affect their ability to judge the feelings, motives, and behavior of themselves and others. This can have catastrophic effects on relationships, especially with children and romantic partners.
Narcissists are not sociopaths. Sociopathy is not a diagnosis. However, the traits of antisocial personality disorder (APD) closely mirror many of the traits people associate with sociopaths. Symptoms of APD include lack of empathy, callousness, disregard for the rights of others, impulsive behavior, deception, and failure to conform to moral norms. People with APD may hurt people or animals, steal, or lie.
NPD is distinct from APD, although APD sometimes co-occurs with NPD. So-called “malignant” narcissists may have co-occurring APD. They may behave aggressively or even sadistically, enjoying a sense of control derived from the pain of others.
The behavior of people with NPD, especially those who have more extensive symptoms, may appear sociopathic. For example, a parent might neglect their child, opting instead to pursue fame and fortune. An employee might lie about their work or co-opt the work of others, even when this costs coworkers their jobs or self-esteem. The distinction here is that narcissistic behavior is motivated by excessive self-involvement that blunts empathy. Sociopathic behavior occurs when a person completely lacks empathy, or when they enjoy the suffering of others.
Personality disorders are difficult to treat. People with narcissistic personality disorder are unlikely to seek treatment and are often highly defensive about their narcissism. Even when they do seek treatment, they may struggle to recognize their narcissistic traits, use therapy as a way to gain admiration, or blame others for their difficulties. Some people with NPD are manipulative and charming. They may even manipulate their therapists. So it’s important that a therapist treating NPD be highly skilled at treating personality disorders.
When a person with NPD enters treatment against their will, treatment is unlikely to work. However, if a therapist can help the person see how NPD undermines the client’s quality of life, relationships, or opportunities for success, this may motivate them to change.
Research on treatment options for NPD is mixed. There are no empirically supported clinical guidelines for treatment, and no drug has been FDA-approved specifically for narcissism. There is no “gold standard” therapy. Treatment instead focuses on specific symptoms, and may evolve as a person’s symptoms and treatment goals change.
People with narcissistic personality disorder can and do change, but only when they are willing to put in significant effort. More extreme narcissism, especially narcissism that co-occurs with antisocial personality, is more resistant to treatment.
Therapy is the most effective treatment for narcissism. Effective therapy focuses on two components of NPD: (1) the emotions and beliefs that drive NPD, such as entitlement; and (2) the behaviors associated with narcissism. Effective therapy involves helping a person with NPD understand how their emotions drive their behavior. A therapist can then work with a client to set goals for behavior changes.
Some treatment approaches that may help include:
- Psychodynamic approaches. Psychodynamic psychotherapy that uses the relationship between the therapist and the client as a way to transform the client’s other relationships may be helpful. This approach to therapy can also support a client to better understand the root causes of their emotions and behaviors.
- Therapy for other personality disorders. Some clinicians find that treatments designed for other personality disorders, such as dialectical behavior therapy (DBT) for borderline personality, can address many symptoms of NPD.
- Approaches that target psychological skills. A 2015 review suggests that mentalization therapy, schema therapy, and transference-focused therapy may be helpful. These approaches each work to help a person understand their emotions and psychological states, so that they can respond to others in less harmful ways.
It’s easy to find narcissism quizzes online, but these tests are not supported by clinical research. Some online tests may incorrectly diagnose people as having conditions they don’t have. Others may miss true narcissism. Many behaviors that seem narcissistic may be motivated by something else. Narcissism and depression, for example, can look similar when depression causes a person to be preoccupied with their own problems.
Rather than seeking a diagnosis from a test, or diagnosing another person based on a few internet articles, it’s best to see a clinician who specializes in personality disorders. Seeking help from a licensed clinician also makes it easier to get effective treatment.
Therapy can help with narcissism. The right therapist can support a person with NPD to understand the effects of their condition and steadily move toward healthier behaviors. Effective therapy for NPD is free of judgment and stigma, and honors the client’s goals.
- Caligor, E., Levy, K. N., & Yeomans, F. E. (2015). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5), 415-422. Retrieved from https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2014.14060723
- Caligor, E., & Petrini, M. J. (2018, May 17). Treatment of narcissistic personality disorder. Retrieved from https://www.uptodate.com/contents/treatment-of-narcissistic-personality-disorder
- Dhawan, N., Kunik, M. E., Oldham, J., & Coverdale, J. (2010). Prevalence and treatment of narcissistic personality disorder in the community: A systematic review. Comprehensive Psychiatry, 51(4), 333-339. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0010440X09000984
- DSM-IV and DSM-5 criteria for the personality disorders [PDF]. (n.d.). American Psychiatric Association.
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