Narcissistic Personality Disorder: A Basic Guide for Providers

A brief overview of identifying, diagnosing, and treating NPD – 4th edition, prepared by Elsa Ronningstam, PhD

Narcissism – From Healthy to Pathological

Narcissism refers to feelings and attitudes towards one’s own self. It is the core of self-esteem and emotions, which influence the way one perceives and relates to others.

Normal narcissism involves a healthy, positive sense of self-worth and self-regard with self-acceptance, curiosity, and compassion, including pride and enjoyment.

Interpersonally, it motivates regard and connection with others, as well as reciprocal sharing with genuine interest in others’ thoughts and feelings, i.e., commitment and empathy. This also promotes an ability to handle challenging situations; to tolerate both criticism and defeat, as well as self-conscious emotions, such as shame, envy, humiliation, frustration, and guilt.

Wished for ideals and attainable aspirations relate to a sense of agency, competence, responsibility, control, and inner mastering of thoughts, feelings, actions, and impulses. Foremost, it relates to the capacity to tolerate, understand, and regulate anger. This promotes self-evaluation with ability to assess and manage stressful or threatening situation as well as losses.

In addition, self-preservation, and ordinary entitlement, i.e., the right to survival and protection of one’s own self and territory, are also part of normal narcissism. All this contribute to an integrated and balanced sense of self and identity, which is reflected in the ability for close mutual and intimate relationships, as well as tolerance of divergences and disagreements.

Exaggerated narcissism or narcissistic personality style, characterized by self-promotion, competitiveness, critical or condescending attitudes towards others, and social maneuvering, is more noticeable in certain age groups or subcultures in today’s society.

Although narcissistic personality style can lead to provocative and challenging interpersonal interactions in private, social, or professional contexts, it is usually not an indication of personality pathology or a psychiatric disorder. It is more related to steadfast self-determination, interpersonal ignorance and arrogance, intolerance of obstacles, and excessive self-preoccupation and self-promotion in certain situations or contexts.

Pathological narcissism differs from normal healthy or exaggerated narcissism foremost because of fluctuating or dysregulated self-esteem and emotions.

People struggling with pathological narcissism make efforts to enhance themselves to protect and support a grandiose but at the same time vulnerable self, and to avoid threats and inferiority caused by negative feelings and experiences, especially reflecting upon the self.

Although narcissistic grandiosity usually has been associated with an overevaluation of own positive, valuable qualities and intentions, recent studies have shown both concurrence and interactions between grandiosity and vulnerability. Excessive self-negativity, i.e., being the worst, a failure, or unworthy and undeserving, can paradoxically spur and empower self-enhancement, with exceptional strivings, control, or effective avoidance.

On the other hand, vulnerability with low self-esteem, insecurity, self-doubts and proneness to self-depriving comparisons and shame can be concealed by self-enhancing extravert, confident, and high aspiring attitudes and presentation. Difficulties tolerating, processing, and regulating feelings, specifically anger, shame, and envy, are common.

Narcissism is the core of self-esteem and emotions

All of this contributes to significant subjective, internal struggles and difficulties for individuals with this pathology.

Pathological narcissism can be expressed in temporary reactions and specific traits, or in a stable, enduring narcissistic personality disorder, NPD. Both pathological narcissism and NPD can co-occur with areas and periods of high functioning, competence, and sense of agency with goals, motivation, and direction, or with intermittent qualities, capabilities, social affiliations, or interpersonal closeness.

When the level of pathological narcissism is less severe, triggered in certain situations, or limited to a set of specific character features, it is referred to as narcissistic pathology or narcissistic traits.

The diagnostic term NPD refers to a stable long-term personality functioning that meets the DSM-5 criteria for NPD or any other comprehensive diagnostic description. Independently of the level of severity, pathological narcissism can either be overt, striking, and obtrusive, or covert, internally concealed and unnoticeable to others.

Fluctuations and interactions between vulnerable and grandiose narcissistic personality functioning are also dependent upon life context and events, which can either challenge or support narcissistic personality functioning, and consequently either escalate or taper down narcissistic pathology.

Engagement in work or studies, and specific interpersonal or community affiliations can sometimes protect or enhance self-esteem, and counterbalance difficulties with self-esteem or absence of close, mutual, and caring interactions with others.

On the other hand, failure to conform to work or study requirements, or to measure up to social or community expectations can be extremely challenging experiences for individuals with pathological narcissism.

Narcissistic Personality Disorder

NPD has so far not been associated with psychiatric or societal urgency or notable public or mental health costs.

Nevertheless, NPD has still met increased recognition as an urgent and complicated mental condition, primarily linked to excessive conflicts in close relationships, marriages, and families, or in work related, social, or legal contexts.

Striking characteristics of NPD usually contribute, i.e., self-enhancement and self-centeredness, with interpersonal insensitivity and critical, competitive, or provocative behavior, along with compromised ability for commitment, collaboration, closeness, and mutuality.

Significant internal suffering in individuals with NPD has also been recognized, although it may remain hidden and unnoticeable to others, or expressed seemingly contradictory, in provocative or antagonistic behavior.

Some people with NPD can present with compromised sense of ethics and accompanying manipulative, deceitful, corruptive, or exploitive behavior.

NPD can also co-occur with other mental conditions that may either escalate symptoms related to pathological narcissism or conceal striking NPD characteristics, such as bipolar disorder, substance use disorder, or major depressive disorder.

NPD has a genetic origin with inherited hypersensitivity, low frustration tolerance, and compromised emotion tolerance and regulation. Early interactions between child and caregiver are influenced by overprotection, leniency, and overevaluation, or alternatively by inconsistency, dismissiveness, and unreliability.

Caregivers’ own aspirations can make them assign roles and expectations onto their child that may reach beyond the child’s own personality and normal developmental needs and functioning.

On the other hand, caregivers’ insecurity can lead to undermining the child’s age appropriate or special capabilities and aspirations. This contributes to overstimulation and under-regulation in the child’s early personality development, which result in problems with self-esteem, self- and emotion-regulation, and sense of identity.

Children who develop NPD may have felt seen and appreciated when they achieve or behave in a certain way that satisfied caregivers’ expectations, but ignored, dismissed, or scolded when they fail to do so.

Some children feel they can never live up to or overcome their idealizing caregivers, while others sense they cannot move away from experiences of being judged and dismissed by them.

Another developmental pattern is noticed in children who at an early age acquire self-sufficiency in response to caregivers’ absence, ignorance, or dysfunction. Those children can, at an early age, become adultified and serve as sustenance for the family or a sounding board for a dysfunctional caregiver.

Alternatively, they can also become parentified and take on adult responsibilities for siblings. For some children, their own development and accomplishments can be perceived as threats to their caregiver and contribute to fluctuations in or loss of the caregiver’s parental care and appreciation.

Absence of or inconsistency in caregivers’ age-appropriate attention and interactive support consequently cause fluctuations in the child’s experience of how he/she is perceived and how he/she sees and experiences him/herself. This affects the formative understanding and perception of both self and others, and more specifically, of expectations in relationship to others.

Dismissive, preoccupied, or avoidant attachment patterns are associated with the development of pathological narcissism and NPD.

NPD in DSM-5

NPD is diagnostically defined in the DSM-5 (APA 2013; pages 669-672) as a pervasive pattern of grandiosity, need for admiration, and lack of empathy, with interpersonal entitlement, exploitiveness, arrogance, and envy. Five out of nine of these criteria need to be present to meet the diagnosis of NPD.

The nine criteria are:

  • DSM 1: Grandiose sense of self-importance (e.g., exaggerates achievement and talents, expects to be recognized as superior without commensurate achievements);
  • DSM 2: Fantasies of unlimited success, power, brilliance, beauty, or ideal love;
  • DSM 3: Belief in being “special” and unique and can only be understood by, or should be associated with, other special or high-status people (or institutions);
  • DSM 4: Requires excessive admiration;
  • DSM 5: Sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations;
  • DSM 6: Interpersonally exploitive, i.e., takes advantage of others to achieve his/her own ends;
  • DSM 7: Lacks empathy; is unwilling to recognize or identify with the feelings and needs of others;
  • DSM 8: Envious of others or believes that others are envious of him/her;
  • DSM 9: Arrogant, haughty behaviors or attitudes.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (2013). American Psychiatric Association.

The NPD diagnosis in DSM has been criticized for being one-sided and relying primarily on external socially and interpersonally striking and provocative features.

As such, it has failed to capture the full range of narcissistic personality pathology, especially the internal vulnerability and insecurity characterized by severe self-criticism, insecurity, confusion, shame, aloneness, and fear.

Instead, the diagnosis has primarily emphasized external characteristics related to boasted grandiosity, and obviously adverse interpersonal functioning.

Important aspects of the patient’s internal distress and painful experiences of self-esteem fluctuations, identity diffusion, and emotional dysregulation have not been included.

In addition, recent research studies have proven that individuals with NPD have compromised empathic functioning with intact ability to recognize and understand others’ feelings and needs, but fluctuating ability or motivation to attend to and engage in others’ emotional experiences.

In other words, people struggling with NPD or pathological narcissism do not lack empathy, but they either chose to refrain from or have difficulties tolerating empathic engagement with others.

In sum, the DSM diagnosis is not considered informative and guiding, neither for patients and people close to them, nor for clinicians and psychotherapists who have been increasingly reluctant to use it.

While some patients strongly oppose being “labeled” NPD, conceiving it as unfair and prejudicial, others have chosen to embrace or identify with the NPD diagnosis as a means for self-definition, power, or attention, and the diagnosis has unfortunately become a practice in combats.

In other words, there is a strong need for explicit explanations and clarifications about the diagnosis and the way the narcissistic pathology influence functioning on the individual, internal as well as mutual interpersonally.

Head with sunrise within and waves behind

People struggling with NPD or pathological narcissism do not lack empathy

Both clinical and empirical studies have confirmed that emotional distress, interpersonal vulnerability, a sense of inadequacy, need for control, avoidance, and fear, pain, and anxiety are important facets of narcissistic personality functioning.

Co-occurrence and fluctuations between self-enhancing grandiosity and self-depreciating vulnerability are also present in narcissistic pathology.

Typical indications of narcissistic vulnerability include inferiority and insecurity, avoidance, shyness, hidden aggressive reactions, shame, and persistent self-negativity.

Paradoxically, hidden excessive self-negativity can also serve empowering, protective, and controlling functions.

Additional characteristics frequently found in patients with NPD are perfectionism and high standards accompanied by self- and other-directed criticism, as well as by preoccupation with fear of not meeting standards and of failing.

In addition, chronic envy, rage, boredom, and emptiness can co-occur with hyper-vigilance and defensive emotional reactivity, especially aggressivity, criticism, and dismissiveness.

NPD – An Alternative Model

A proposed hybrid model with combined diagnostic dimensions and traits was included in DSM-5, Section III Alternative Model for Personality Disorders, AMPD, (APA 2013).

This diagnostic model identifies specific difficulties and impairments in personality functioning, i.e., in identity and self-direction related to self, and empathy and intimacy in relation to others. In addition, there are specific personality traits that signifies each personality disorder.

The typical features of NPD (pages 767-768) attend primarily to the vulnerable and fluctuating self-esteem and the range of interpersonal patterns.

Moderate or greater impairment in NPD is found in the following areas of personality functioning:

  1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal—inflated or deflated or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem.
  2. Self-direction: Goal-setting based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
  3. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimates own effects on others.
  4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.

Two personality traits identify NPD:

  1. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending towards others.
  2. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (2013). American Psychiatric Association.

This NPD diagnosis is defined as a combination of significant problems within the 4 areas of personality functioning and at least 1 of the two personality traits.

In addition, impairment in functioning and trait expressions should be persistent across different personal and social situations, stable over time, not explained by other mental or medical conditions, and evaluated in the context of the individual’s developmental stage and sociocultural context.

This new diagnostic model is more clinically meaningful and informative for both patients and clinicians. It is descriptive and captures a broader range of narcissistic personality functioning, including fluctuations and variations in both context and severity of pathology.

It also invites attention to individual motivation and self-regulatory internal as well as interpersonal patterns and intentions. It connects fluctuations in self-esteem, i.e., superiority and inferiority, with identity problems, and inconsistent goals and motivation.

Foremost, this model focuses on the complex interpersonal functioning, i.e., the need for others’ support of own self-esteem and sense of identity, combined with self-preoccupation, compromised ability for empathy, and inattentions to others’ needs and reactions. In sum, fluctuations in personal, internally driven self-enhancement co-occur with intense needs for others’ attention and admiration, as well as with distancing and disinterest in relationship to others.

Still being a proposed model for diagnosis of personality disorders, this model is presently guiding continuing research on identifying pathological personality functioning and disorders.

Individuals With Pathological Narcissism or NPD

Individuals struggling with pathological narcissism or NPD can come across quite differently; there is no real standard prototype.

Some individuals are professionally successful, consistently high-functioning, and socially well-connected, only showing reactivity, distancing, and avoidance in certain contexts.

Others can present with functional fluctuations or specific impairment, either with severely disabling narcissistic traits and character functioning, or with accompanying mental disorders, such as mood disorder (major depression, dysthymia, bipolar disorder), substance use disorder, or eating disorder, or obsessive compulsive disorder.

Some individuals can have accompanying somatic conditions that in different ways affect their self-esteem, motivation, or sense of identity. Still others can engage in occasional illegal behavior, and those with more severe malignant narcissism can have antisocial or psychopathic behavior such as violent revengefulness, exploitation, and hostility.

Fluctuations in pathological narcissism and changes towards worsening as well as improvement in narcissistic personality functioning are often influenced by real life events (e.g., vocational, social, interpersonal, marital, or family, medical, or financial).

Such events can be perceived or experienced by the individual as threatening or corrosive in ways that escalate pathological narcissistic traits and functioning.

Alternatively, they can also be experienced as supportive, confirming, and encouraging or even corrective, leading to new realizations, stabilized self-esteem, and decreases in pathological narcissistic functioning.

People with pathological narcissism or NPD may have strengths and abilities in certain areas, i.e., in their professional or social lives, or in certain types of relationships, which they find supportive of their self-esteem, sense of identity, and/or interpersonal functioning.

However, they can still present with severe vulnerabilities or external pathological narcissistic patterns in other areas: especially in intimate relations, parental roles, certain social, professional, or work-related situations, or in their moral and ethical standards or behavior.

Consequently, people with NPD can experience themselves and come across differently in different social or interpersonal contexts. The same person may feel confident and competent, or act in a convincingly dominant and assertive way in one setting. In another they may feel shy and avoidant, or insecure, easily humiliated, and struggling with loss of control, feelings of envy or resentment, or with fear of failing or being exposed.

In addition, certain circumstances and experiences can evoke or aggravate narcissistic traits in response to challenging or traumatic experiences. This can evoke interpersonal provocative, critical, and aggressive behavior.

Some experiences can be perceived as traumatic because they take on a subjective frightening meaning, or can activate earlier narcissistic trauma, which consequently can threaten the person’s self-esteem, and sense affiliation, coherence, stability, and well-being. On the other hand, certain events and experiences can readily be seen as organizing and consoling, and hence enabling access to proactive confidence.

Some people choose to take on narcissistic pathology as a sense of identity, presenting themselves as “I am a narcissist,” especially in response to being told or accused of “being narcissistic” or having NPD.

Such self-characterization may paradoxically serve an empowering function that can help to shield actual internal vulnerability or interpersonal struggles related to self-esteem and emotions.

Ability for self-reflection and forming coherent meaningful narratives of deeper personal experiences is often compromised.

Recognizable Individual Variations

When people with pathological narcissism or NPD seek treatment they can present in many different ways. Some match the typical expectation of a narcissistic personality by being self-promoting, self-absorbed, and interpersonally provocative. Others effectively hide their narcissistic characteristics and can initially be friendly and tuned in, but gradually turn distant and aloof.

Some individuals present with corrupt and antisocial traits, while others take pride in their high moral and ethical standards. Some are boastful, assertive, and arrogant; others can be modest and unassuming with an air of grace; and yet others can present as perpetual failures while constantly being driven by unattainable, grandiose aims.

One person can be charming and friendly, another shy, quiet, and vulnerable, yet another domineering, maneuvering, aggressive, and manipulative.

When people with pathological narcissism or NPD seek treatment they can present in many different ways.

Some are intrusive and controlling; others are evasive and avoidant. Some can openly and bluntly exhibit most extreme narcissistic features and strivings, but still hide more significant narcissistic personality problems. Others are perfectionists, driven by high standards, and extreme demands both related to themselves and others.

Absence of symptoms and experiences of suffering can be a paradoxical blessing for some people with NPD. Others, however, can struggle with severe internal suffering, including harsh self-criticism, self-doubt, fear, shame, insecurity, and anger that may or may not be expressed.

Some individuals can provide well-informed and articulate accounts of their pathological narcissistic functioning with insights in interpersonal patterns or contributing developmental experiences. Others may be totally oblivious of their problems, assigning blame on others, or even feeling forced to seek treatment.

Nevertheless, the common indications of narcissistic personality functioning include apparent or concealed self-enhancement with self-esteem fluctuations, vulnerability, and inferiority, and fear of losing control and failing. Avoidance, control, and distancing are key patterns.

Ambiguity and fluctuations in sense of identity are common. Some may be aware of their limitations in interpersonal relationships, with compromised empathic functioning and intense reactions to criticism and threats to self-esteem, with strong need for control.

Others tend to primarily externalize and criticize others. Still others may take charge of their diagnosis and identify with several of the common traits without identifying and taking ownership of their own real problems.

Internal Struggle and Reactivity

Contrary to the external confidence, arrogance, and insensitivity, people with pathological narcissism and NPD tend to struggle with a shifting and conflicting sense of self and identity. Underneath a more noticeable self-praising or self-enhancing outward facade they can be excessively self-critical and judgmental. Some struggle with perfectionism and exceptionally high standards for themselves, and sometimes for others too.

Strong reactions to perceived threats to self-esteem, such as humiliation, defeats, criticism, failures, or others’ envy, are common.

Such reactions can include intense feelings that are either openly expressed or hidden (anger/hostility, envy, shame, or fear), mood shifts (irritability, anxiety, depressive symptoms, or elation), or deceitful or retaliating behavior (aggressive, antisocial, or suicidal behavior).

Strong reactions indicate fluctuations in self-esteem, which can alter between states of overconfidence, superiority, and assertiveness, and states of inferiority, insecurity, and incompetence (grandiosity and vulnerability).

In addition to not knowing their own motivations, people with NPD can also have a compromised sense of identity and not knowing who they really are or what they want. Their sense of self-agency, i.e., goals, directions, and determination, is influenced by a need for internal control, a sense of self-sufficiency, and avoidance of threats or challenges to self-esteem, with a reluctance or inability to rely on others.

Self-enhancement and self-preoccupation serve as a protective armor by shielding or hiding low self-esteem, harsh self-criticism, insecurity, inferiority, shame, loneliness, detachment, and fear.

This excessive internal self-negativity, often mistakenly perceived as depressive disorder, can paradoxically be part of the narcissistic self-enhancement by providing self-defining control and justifying avoidance (“I am a failure,” “I do not deserve,” “Nobody can understand or help me,” “I am my own worst enemy,” etc.).

Interpersonal Functioning

Signs of individuals’ narcissistic traits or functional patterns have often been identified in their interpersonal interactions.

Spouses, relatives, friends, or colleagues can notice an avoidant distancing pattern with lack of motivation to relate closely, or alternatively, an eager attention seeking preoccupation with expectations or demands on others to satisfy their needs and longings.

Entitled, arrogant, aggressive, or competitive ways of relating can be typical for some. Others can be extraordinarily attentive, reliable, and tuned in as long as they feel they get the approval or support they need, while some typically show a more consistent critical, dismissive, or devaluing attitude or way of relating.

People with pathological narcissism or NPD can be both vulnerable and insensitive to others’ feedback. They are vigilant to perceived rivalry and rejections and may readily take on an empowering victim role, blaming others for not being able to measure up to their own standards.

Tendencies to combat and retaliate towards alleged criticism or disagreement is common, but retreat into self-sufficiency or self-absorption without noticeable reactions can also be an engrained pattern. Longstanding envy, resentment, or animosity can spur further distancing.

Especially in long-term relationships, enduring combative, retaliating patterns can co-occur with dependency and even love.

Some people may easily feel criticized, degraded, mistreated, or ignored by the person with pathological narcissism, but some may feel, at least partially or intermittently, highly valued, idealized, and relied upon.

In higher functioning people with more compartmentalized pathological narcissism, longstanding constructive, collaborative relationships may co-exist with other deeply conflictual, distant, or contentious personal relationships.

Difficulties to access, identify, tolerate, and verbalize emotions are typical for individuals with pathological narcissism or NPD.

Such deficits affect their ability to maintain close, mutual relationships. Tendencies to extract, avoid, or isolate from others can be a way to sustain superiority and self-enhancing fantasies, i.e., a “splendid isolation,” but such removal from others can also be driven by shame and fear of exposure or failure.

Vocational Functioning

The ability to work, and to remain devoted to professional commitment both in times of success as well as during challenges and setbacks, are significant indications of agency and sustainable competence that can be present in higher functioning people with NPD.

For those who successfully worked under stable conditions for decades, sudden changes, setbacks, or interruptions in their work context can be narcissistically traumatizing, leading to excessive self-doubts, self-criticism, and loss of professional identity.

Some individuals can have exceptional abilities in creativity, innovation, or leadership and be more project oriented. Others can present with temporary achievements and a history of occasional or irregular accomplishments, or a one-time top achievement under favorable circumstances.

All of this can indicate actual or potential capabilities that are hampered by changes in vocational conditions or by fluctuations or vulnerabilities in self-esteem or interpersonal relations.

However, such transient achievements can, for some people with less sustaining capability, be the result of favorable temporary circumstances that support self-enhancing and self-serving behavior.

Individuals whose work includes both own expertise as well as team collaboration or leadership can repeatedly find themselves in unmanageable situations, feeling threatened, dismissed, or intruded upon by others’ opinions and demands.

Aspirations and envisions of outstanding success and accomplishments are common and natural in young people facing the beginning of their educational and professional careers.

The balance between self-esteem and direction, and the integration of experiences of success and disappointments with realizations of competence and limitations are essential for continuing functioning and developing of vocational identity and direction.

Clinician Training

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McLean’s Gunderson Personality Disorders Institute offers training and continuing education for health professionals focused on treating borderline personality disorder and other personality disorders. Learn more about upcoming courses.

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Explanations of Some Narcissistic Dimensions and Facets

Grandiosity – Vulnerability

Grandiosity has long been considered the core trait and the most outstanding characteristic for NPD. However, studies have shown that not only is grandiosity reactive and dependent upon mental state, but it also co-occurs and fluctuates with vulnerability, inferiority, and insecurity.

Grandiosity, superiority, and other self-enhancing strategies can be spurred by external experiences that concur with ideals, aspirations, and perfectionism, but it can also be hidden in internal convictions or fantasies that support the sense of special, unique, or exceptional qualities. Interpersonal experiences can affect the grandiose self-esteem depending upon whether they are perceived as potentially supportive or threatening.

A continuous and often determined search for others’ approval or admiration is typical, as is the use of interpersonal self-regulatory strategies such as taking advantage of others, entitlement and expecting special treatment, or blaming others for failures. In the context of self-esteem and self-regulation, grandiosity signifies these types of self-enhancing patterns that are central to pathological narcissism and NPD.

Vulnerability, on the other hand, can relate to insecurity, shame proneness, underlying psychological trauma, or general inconsistency or unreliability of own capability and thinking. The grandiosity-vulnerability range is often accompanied by an uncompromising “black or white,” and “either-or” thinking, especially related to “success or failure,” and “winning or losing,” which add to internal insecurity, self-condemnation, and fear.

Sudden threats to self-esteem or to more favorable self-images can temporarily increase defensive grandiose thoughts and behaviors, such as fantasies and aspirations, competitive or bragging behavior, and hostility or devaluation of others.

Alternatively, such threats can also cause unexpected fluctuations in or loss of self-esteem with shame, fear, and detachment.

Grandiosity can be challenged by brief depressive reactions or a major depressive disorder causing a more self-critical and humbler attitude. Moving from late adolescence to adulthood with expectations of reality anchored competence with demands and outcome can involve another challenge to grandiosity.

Likewise, aging and facing retirement with accompanying changes and limitations can also cause increases in defensive or enhancing pathological narcissism. In addition, changes in appearance, beauty, physical competence, or health, which can occur at any time in life, may cause significant narcissistic reactivity and shifts in self-esteem.

Perfectionism – Self-Criticism

Perfectionism with high standards and ideals have long been considered a significant part of narcissistic personality functioning. Some readily talk about their perfectionism, while others are more hesitant and keep it secret.

Perfectionism has several forms and meanings, i.e., the mandate to feel or be perfect, a requirement coming either from oneself or from outside. This can contribute to vulnerable self-esteem and to problems in relationships and accomplishments, leading to shame, self-criticism, and hypervigilance.

Perfectionism can also relate to self-presentation, i.e., to appear perfect, which becomes more interpersonally problematic as it involves hiding and concealing everything that is non-perfect. Especially, it can lead to a reluctance to recognize or admit own imperfections and to seek help.

A third aspect of perfectionism relates to achievement, i.e., to perform perfectly, like getting an A+ on a paper, winning the prestigious award, or getting the aspired promotion, which can become an unconditional measure of self-worth.

As perfectionist standards often can be unrealistic or unattainable, perfectionism is usually accompanied by self-criticism, which can develop into an ongoing inner judgmental process, leading to self-deprivation, withdrawal, and feelings of severe insecurity and inferiority.

Exposure – Avoidance

Being and feeling seen and attended to can for some people with narcissistic personality functioning be very important, and they desire and feel confident facing exposure and publicity. Their sense of identity and self-esteem are strongly related to visible performance, with directions and goals.

Some individuals can sustain such devoted functioning even for a long period in their lives.

Sudden loss of this identity defining attention, caused either by failing or being disapproved of or competitively sidelined, can cause a personal crisis with significantly escalating narcissistic pathology and accompanying depressive reactions, substance misuse, or even suicidality.

For others who are more hypervigilant and sensitive, publicity inevitably involves the risk of either or both exposing shortcomings or imperfections, with failure to meet standards and expectations, or anticipating facing others’ negative judgments.

This makes exposure in public or interpersonal situations extremely uncomfortable or even threatening, and avoidance or even isolation become the consistent and effective way to protect against the anticipated risks of being seen.

Anger – Shame – Fear

Anger and rage have long been considered central affects in NPD, especially indicated by assertive, forceful, defensive, or critical reactivity, and by arrogant, inconsiderate, exploitive, or retaliatory interpersonal behavior. Anger in the context of pathological narcissism can have either a motivational or a reactive cause.

In interpersonal context it can serve to protect against perceived danger, or to restore self-esteem and internal power. When driven by entitlement or feelings of envy, it can result in attacking, injuring, or defeating others.

Turned towards self, anger and rage can lead to severe self-criticism, self-hatred, and suicidal ideations with intentions to end life.

Narcissism related anger and rage may be effectively controlled, hidden, denied, or compartmentalized in individuals with pathological narcissism or NPD. It can also be integrated in a skillful, well planned, and accomplished way for personal gain or interpersonal damage.

Shame can be experienced as intrusive, tormenting, and sometimes paralyzing, but can also be hidden, bypassed, and not felt or identified at all. Shame can also be expressed in chronic low self-esteem, feeling undeserving, bad, or worthless, or in aggressive reactive behavior, rage outbursts, and suicide.

Shame in the context of perfectionism is a painful response to facing unacceptable, imperfect aspects of oneself as they could be seen and judged by others in social interpersonal contexts. This can even be experienced as traumatizing by the individual.

Shame in the context of anger, on the other hand, can serve both as a trigger of aggression, i.e., shame-based aggressive reactions, or as a disguise where the shame contributes to hiding or avoiding the anger.

Feelings of fear is often considered counterintuitive to narcissism and seemingly contraindicating to typical narcissistic traits, such as assertive self-enhancement, aggressive dominance, and competitive achievements.

Nevertheless, fear can underlie achievements and perfectionism, and serve both as a motivator to succeed and as the core of insecurity and anticipation of loss or failure. Fear can also counteract exposure, i.e., “fear of being seen,” and lead to procrastination and avoidance.

Anger, fear, and shame often co-occur and can sometimes interact in complex and confusing ways, making it difficult to separate and identify which is which and what cause and contribute to each emotion.

Anger can evoke shame, and shame can evoke anger as well as powerlessness and fear. On the other hand, fear can also evoke anger as well as shame.

Compromised Empathy

Empathy refers to the ability to recognize and understand the emotional state of others, and to identify and feel their feelings and needs. Empathy requires both tolerance and appreciation of own as well as of other’s emotions.

Recent research has identified empathy as a complex process involving both internal psychological, interpersonal, and neuro-cognitive factors.

Empathy is an important part of self and self-esteem regulation, and crucial for the ability to manage interpersonal relationships.

Studies have shown that people with NPD can notice and understand others’ internal states and feelings but may not be able to emotionally engage in and respond to them. In other words, people with pathological narcissism or NPD have compromised and fluctuating empathy, but they do not lack empathy.

Self-centeredness, emotional dysregulation (insensitivity or difficulties tolerating and processing some of one’s own and others’ emotions), self-esteem dysregulation (fluctuations between self-enhanced grandiosity and self-vigilant depreciating vulnerability), or difficulties feeling deeper care and concern can contribute to compromised empathy.

Individuals with pathological narcissism or NPD may be able to appropriately empathize under certain circumstances, when feeling in control or when their self-esteem is unchallenged or even promoted by their ability and motivation for empathic responses to others. Their motivation and desire for empathizing may also vary depending upon the interpersonal context and perceived advantages.

Some can empathize more with others’ positive feelings and success-related experiences than with others’ negative feelings or defeats, and vice versa. Those influenced by envy can be unable to tolerate others’ positive events and experiences, while those who tend to mirror themselves in the light of others may perceive others’ success as an opportunity for self-enhancement.

Similarly, those who readily feel contempt can find others’ defeats and losses despicable. As a result, they chose to secure their own superiority or perfectionism in the comparison between self and the suffering other.

Some individuals can empathize under certain circumstances, e.g., when asked for advice by a friend who has marital problems but being unable to relate to own marital problems as pointed out by the spouse.

Others have limited ability to tolerate the emotions they see in others and feel in themselves, resulting in their dismissing and withdrawal from attention and care for someone struggling.

In sum, compromised empathic functioning in individuals with pathological narcissism or NPD can cause interpersonal conflicts, fluctuating or low self-esteem, and underlying insecurity.

The perception of others’ feeling states can evoke overwhelming powerlessness, disgust, shame, or loss of internal control, and trigger strong critical, dismissive, or aggressive reactions, or even emotional and/or physical withdrawal.

Some individuals are aware of and want to respond to others but feel overwhelmingly provoked or incapable. Others deliberately ignore others’ feelings or needs based on their own prioritizing. The individual him/herself may or may not be aware of such deficits or choices and their interpersonal consequences.

The Narcissistic Trauma

An external life event, which not only threatens the individual’s self-esteem but also bring loss of hope, ideals, and meaning, can cause a narcissistic trauma.

Such trauma is characterized by a sense of failing competence with loss of values and self-worth, or loss of connections or affiliations to others. This may potentially become overwhelming, intolerable, and even terrifying.

It is the individual’s own internal perceptions and interpretations of the external event, as well as his/her own accompanying overwhelming reactions that become narcissistically traumatic, mainly because they challenge or damage supportive or sustaining experiences and functions of both self and others.

Especially difficult for the self-esteem are sudden unexpected experiences of demotions and other work-related failures, financial setbacks and bankruptcies, personal rejections or betrayals, infidelity, divorces, or legal problems.

Although not necessarily inherently traumatic, the specific subjective meaning assigned to such events contributes to an inner psychological traumatic experience.

This differentiates a narcissistic trauma from a trauma in which the actual external event, i.e., abuse, terror, torture, accidents, catastrophes, losses, or illness, i.e., conditions that cause social, physical, and mental challenges or hardship, defines and contributes to an internal impact and experience of suffering.

The first type of trauma cause trauma associated narcissistic symptoms, TANS, including overwhelming shame, humiliation, and rage, while the second type of trauma is related to post traumatic stress disorder, PTSD, primarily associated with severe anxiety.


People with narcissistic personalities are particularly vulnerable to suicide. Studies have indicated that experiences of sudden or gradually escalating challenges to self-esteem and sense of control are major contributing factors. Internal fluctuating self-esteem, accompanying intense emotional reactions, and fragile interpersonal relationships are other contributing personality factors.

In contrast to patients with borderline personality disorder, BPD, those with NPD do not engage in deliberate self-harm. In addition, they can have suicidal thoughts and impulses in the absence of depression, i.e., major depressive disorder or depressive symptoms as psychiatric condition, as well as personality related depressive feelings or excessive self-negativity. For example, suicide can serve as a means to attack or destroy the perceived imperfect aspects of the self.

People with narcissistic personalities are particularly vulnerable to suicide.

Narcissistic vulnerability, i.e., the susceptibility to feeling shame, humiliation, anger, or rage, as well as being sensitive to failure and defeat, make certain kinds of stressful life events more life-endangering and suicide evoking. Such events, which are considered particularly pernicious for people with narcissistic pathology, can include legal or disciplinary problems, changes, or losses in professional, social, or personal affiliations, physical illness, financial problems, and aging with age-related transitions and limitations.

Suicidal ideations can serve emotional and interpersonal self-regulatory functions, and the patient with NPD may ascribe a certain personal subjective meaning or function to suicide. Sometimes the idea of suicide can protect against threats, trauma, or defeats, and represent an illusion of mastery, control, or indestructibility, like a “way out.”

Some individuals can have life-sustaining suicidal ideations that can serve to control and process unbearable feelings or conditions. Such ideations can actually help to protect and maintain connections to life and promote the incentive to stay alive.

Paradoxically, for people with these types of sustaining suicidal preoccupations, the thought and awareness of their ability to end their own life can have an organizing and structuring effect, and in some cases, make their lives more livable and even enjoyable.

Prevalence, Gender, and Age

The prevalence of NPD has been estimated to up to 6% in general population, up to 17% in clinical population, and between 8.5-20% in outpatient private practice. Some studies have found NPD to be more common and disabling in men, while others have found NPD equally prevalent in both men and women.

Nevertheless, narcissistic pathology can have different female and male related causes and patterns. For women, balancing sense of identity and self-esteem as a wife, mother, and professional can be challenging. Similarly for men, balancing financial responsibilities with relationship to wife and children can cause self-doubts and escalate early developmental experiences.

The transition from adolescence to adulthood tend to escalate narcissism related challenges, and exaggerated narcissism with features of pathological narcissism can be more frequent among teenagers and young adults.

Struggle with sense of self and identity, aspirations, relationships, and social belonging in a time of separation from childhood and parental dependency towards adult individuation and autonomy can be specifically challenging.

In addition, this time in life involves competition, navigating social media, exploring and accepting sense of identity, and incorporating aspirations and ideals when deciding and applying for educational/vocational track or professional direction.

Narcissistic disturbances related to this time are usually corrected through developmental life experiences and normally do not develop into adult NPD.

NPD does not necessarily remit with advanced age. Middle age is an especially critical period for the development or worsening of NPD, and narcissistic pathology and personality disorder have also been found in elderly people.

Similarly, cultural differences and facing acculturation and adjustment after migration can escalate defensive narcissistic reactions and pathological narcissistic traits.

Cultural Aspects of Healthy and Pathological Narcissism

Attention to the individual’s cultural and societal context is very important for understanding and diagnosing pathological narcissism and NPD.

Differences between traditional, social, religious, or family oriented versus modern competitive, individualistic, and elitist societies and sub-cultures tend to affect personality functioning, especially in the context of moving, joining, and adopting to new cultures.

Some core problems in narcissistic personality functioning can be highly influenced by cultural norms or changes, especially related to sense of identity, self-esteem, and interpersonal functioning.

In the context of moving or facing subcultural differences, gaps between expected and real encounters can be disappointing or shocking. Hopes and envisions can turn into uncertainty, fear, and avoidance, and diminish the ability to embrace, accommodate, and grow in the new cultural or social context.

On the other hand, moves and acculturation can also open opportunities that allow proactive narcissistic personal development related to special competence, aspirations, creativity, career, influence, and sense of social or professional belonging, etc.

Insecurity and self-doubt related to sociocultural differences can co-occur with increasing competence and educational or professional advancement, and sense of social and personal fitting and closeness.

Young, talented people moving into educational or career opportunities can struggle with inner confusion, shame, or guilt when facing cultural and personal differences compared to their background.

Marrying into a family with different sociocultural or economic conditions can escalate unexpected narcissistic challenges related to values, behavior, and relational patterns.

Different cultures or social contexts also have different narcissism related personality styles, some being more visible success focused, competitive, flamboyant, or self-affirming while others tending to be more shame prone and valuing modesty and self-criticism, with loyalty and social commitment.

Psychological adjustment in either direction can be challenging for the individual’s sense of identity and cause internal conflicts with interpersonal hypervigilance and insecurity that mistakenly can be considered narcissistic personality pathology.

Co-Occurrence With Other Disorders

NPD and Borderline Personality Disorder, BPD

NPD often co-occurs with BPD, and the two disorders share emotion dysregulation, reactivity, and unstable relationships. Other similarities include sensitivity to criticism, aggressivity, and entitlement.

Borderline patients struggle with intolerance of aloneness, impulsive behavior, and lapses in reality-testing as major reactions to separateness or abandonment. Narcissistic patients on the other hand, have intolerance of threats to self-esteem with intense reactions, including protective cognitive and interpersonal maneuvers and feelings of rage and shame, in response to such threats.

However, while borderlines’ reactivity is more consistently noticeable, the narcissistic reactions may be expressed in overt anger, or self-enhancing or self-serving behavior, but can also remain hidden or unnoticeable to others. Intolerance of intense emotions and need for internal control also influence reactions in NPD.

Studies of the pathogenesis of BPD have identified insecure attachment, parental separations and losses, and experiences of abuse as significant for the development of borderline pathology.

Comparable developmental challenges for NPD include avoidant and dismissive attachment, parental projections, expectations and role assignments, psychological trauma, and inconsistency or imbalance between gratification (spoiling, idealization) and age-appropriate, reality anchoring challenges, limitations, and boundaries.

Narcissistic traits can co-occur in BPD and influence the borderline functioning and symptoms.

Self-destructive preoccupation in narcissistic-borderline patients can be expressed in a particular combination of controlled, thrill-seeking, or risk-taking self-destructive behavior, which serve both to conquer subjective feelings of badness, as well as to maintain superior control.

In other words, the narcissistic capacity for higher impulse control is attached to a borderline preoccupation with self-destructiveness, leading to a superior experience of balance between life and death, between control and destructiveness. When borderline traits co-occur in NPD, the patient may be more able to tolerate and process emotions and attend to interpersonal challenges.

NPD and Antisocial Personality Disorder, ASPD

NPD can co-occur with antisocial personality disorder, ASPD, and its variant psychopathy. In contrast to those with ASPD, people with NPD normally do not display recurrent antisocial behavior, but they can occasionally commit criminal acts in a state of rage or competition. They can be motivated by self-enhancement to reach potential gains, or by avoidance of anticipated exposure and defeat.

People with ASPD demonstrate more persistent and recurrent dishonesty, failures in moral and ethical behavior, callousness, disregard, manipulativeness, and risk taking.

Exploitiveness in antisocial people is more likely to be consciously and actively related to material or sexual gain, while people with NPD tend to take advantage of others passively or unwittingly as part of their self-regulation and self-enhancement. Impaired emotional empathic capacity is present in both disorders.

When narcissistic traits co-occur with ASPD and psychopathy, the combination of self-enhancement and compromised moral and ethical functioning can be reflected in drug and alcohol misuse, chronically unstable antisocial and criminal lifestyle, impulsivity, and sensation seeking.

Some people with NPD who present closer to the psychopathy range can be ruthlessly insensitive, entitled to be charming, cunning, or exploitative, with manipulative and sadistic behavior.

NPD and Bipolar Spectrum Disorder

Self-enhancement in NPD and mood elevation (hypomania) in bipolar disorders can appear similar, but they have distinctly different origins and phenomenology.

Self-enhancement and heightened self-esteem in NPD represent a long-term pervasive characterological pattern, accompanied by intense reactions to perceived threats to self-regard. People with bipolar disorder have autonomous underlying mood shifts, which in elevated states can cause temporarily inflated self-esteem.

Patients with bipolar disorder in hypomanic and acute manic phases can exhibit some of the core characteristics of NPD, i.e., self-enhancement, self-centeredness, entitlement, insensitivity, and arrogant, boastful/ pretentious behavior.

Notable differences are that NPD patients more actively pursue admiring attention, showing contemptuousness and critical devaluation of others, revengeful rage, and denial. In addition, there is no evidence of a narcissistic character structure or consistent features of pathological narcissism in bipolar patients when they are euthymic.

When bipolarity and pathological narcissism co-occur, there can be an interactive progressive process so that events and experiences affecting narcissistic personality functioning can evoke mood swings, which can have a major impact on narcissistic self-esteem and affect dysregulation.

Consequently, in some people with NPD, mood elevation combined with the capability to integrate high energy with proactive, competent activity level can lead to periods of quite successful productive functioning, resulting in valuable or even exceptional professional or creative achievements.

In others, who feel their sense of control is threatened by mood shifts, such mood elevations can be extremely uncomfortable and even frightening.

Learn more about bipolar disorder

NPD and Depressive Disorder

Depressive symptoms are relatively common in patients with NPD. Most frequent indicators are loss of interest and enjoyment, low energy, and a consistently negative state of mind.

Feelings of shame, hopelessness, emptiness, and meaninglessness are usually underlying these signs of depression. Reactive depression often co-occurs with threatened or depleted self-esteem caused by defeats, failures, or losses.

Individual’s experiences of loss of status, control, or sense of competence or agency, can evoke strong feelings of worthlessness, powerlessness, envy, or rage. More consistent self-negativity with self-criticism or self-directed hatred, combined with a deep sense of being a failure and unable to measure up to own standards or ideals, can contribute to depressive symptoms, dysthymia, or anhedonia.

Patients with pathological narcissism or NPD may have difficulties identifying such feelings and describe their cause and context, but rather tend to present with and describe typical symptoms of depression.

Life related narcissistic challenges, such as reaching midlife and aging, can also evoke chronic patterns of devaluation, bitterness, resentment, or pessimism connected to loss of important purpose and function in life, when facing limitations and aloneness.

Paradoxically, individuals with pathological narcissism or NPD can also, because of low affect tolerance or inability to identify or attend to negative emotions, engage in different ways of avoiding such overwhelming feelings states.

Suicidal ideations and plans can, as mentioned above, in the absence of depression, serve such escape. Similarly, substance use, gambling, or other escapist activities can be driven by severe underlying negative emotions or preoccupation.

Depressive disorder or symptoms in patients with pathological narcissism or NPD do co-occur with severe underlying narcissistic pathology.

Consequently, it is very important in assessment and treatment planning to attend to the patient’s personality functioning and underlying feelings, as well as to their life context and the subjective meaning of specific life events or ongoing circumstances.

Often depression in these patients is primarily related to narcissistic self-negativity, vulnerability, and reactivity, and may or may not be treatable or remittable with psychopharmacological treatment, TMS, or ECT. Instead, it needs to be addressed in a combined supportive and gradually exploratory psychotherapy.

Learn more about depression

NPD and Substance Use Disorder, SUD

NPD can be a predisposing factor or a secondary consequence to SUD, but the two conditions can also be reciprocal and mutually escalating each other.

In addition to serving a defensive function against intolerable feelings, substance use can paradoxically also have a sustaining and even enhancing effect on self-esteem, and sense of mastery and control in people with NPD.

Similarly, substance use can also affect their ability to relate with improved interpersonal flexibility and tolerance.

Some high functioning people with NPD and controlled substance dependency, foremost alcohol, can have the ability to hide and regulate their consumption.

For long periods of time, they may even be able to maintain professional competence and successful careers while taking pride in hiding and controlling their addiction.

However, substance use can, for some people with NPD, induce a sense of omnipotence with increased risk taking and immobilizing of regular judgment and self-preservation, which ultimately can be life threatening and lead to suicide.

For others, devotion to substances can serve as a self-authorized protective retreat that justifies avoidance of involvement.

Learn more about substance addiction


The often symptom-free individual with NPD usually seeks treatment primarily because of acute crises caused by vocational or personal failures or losses, requests or ultimatums from family, employer, or court, or in the context of an increasing sense of dissatisfaction or meaninglessness in his or her own life.

In addition, co-occurrence of other uncontrollable mental conditions, such as substance use or mood disorder, can motivate or enforce treatment.

Level of motivation varies depending upon the patient’s experiences of urgency, necessity, or ultimatum. In addition, the absence versus availability of outside sources of support, which can help sustain continuing individual narcissistic function and lifestyle, also influence motivation and connection in treatment.

Alliance building in treatment is challenging, as patients with NPD tend to be critical, avoidant, or dismissive. Others can be tuned in, articulate, and seductive while still hiding and avoiding addressing real problems.

The therapist’s observations of the narcissistic patients’ functioning often do not concur with the patients’ own experiences of themselves or formulations of their problems.

Clinician talks to patient

The choice of therapeutic interventions and strategies should be adjusted to the individual patient’s problems and functioning

Some aspects of narcissistic pathology can be more externally noticeable or provocative, but the patient may be unaware of, or unable or unwilling to address such problems at an early stage in treatment. On the other hand, the patient may readily identify and struggle with problems that are seemingly irrelevant or dismissed by others, including therapists.

Some patients can enter treatment with ostensibly fixed and convincing descriptions of themselves and their problems that initially imply narcissistic personality patterns or the NPD diagnosis.

Further explorations may disclose that such diagnostic self-assignments serve to control or maneuver conflictual and accusatory marital or family interactions rather than indicating own awareness and experiences of narcissism related problems with self and others.

Others may have deeply rooted negative experiences or trauma that caused the development of narcissistic pathological functioning, and it may take significant time of building alliance and trust until those can be accessible to process in psychotherapy.

For some patients, the possibility of confirming narcissistic pathology or receiving the NPD diagnosis when starting treatment can be extremely challenging and evoke deep shame and hopelessness.

These patients have often gained wrongfully biased and negative information about narcissism and NPD and may need the benefits of initial diagnostic psychoeducation.

Alternatively, some patients may benefit most by focusing treatment on their own goals with choosing, understanding, and processing their own understanding and experiences of their problems.

A flexible, collaborative, exploratory treatment approach, adjusted to the individual patient’s functioning, motivation, and degree of self-awareness and self-reflective ability, is strongly recommended. It is necessary to balance patients’ urges to reject and devalue the therapist and drop out of treatment with efforts to encourage and support them to face and reflect upon their own experiences and behavior.

Reaching a mutual agreement and understanding of each individual patient’s purpose for seeking treatment, their goals, and individual psychological ability and motivation for change are the most important initial tasks.

The therapist or clinician should focus on problems that are experienced as urgent and relevant for the patient and identify his/her own understanding and description of these problems.

It is important to engage the patient’s own curiosity, sense of agency, and active collaborative involvement. This can, with some patients, take many sessions, and be integrated with the building of a therapeutic alliance.

Equally important is to adhere to a respectful, nonjudgmental, attentive, and task-focused therapeutic attitude. Keeping in mind that many striking narcissistic characteristics and patterns indeed can serve a protective function for the patient’s brittle sense of identity, internal control, and self-esteem can help guide and balance the therapist’s approach and choice of focus and interventions.

The choice of therapeutic interventions and strategies should be adjusted to the individual patient’s problems and functioning.

The patient’s motivation, curiosity, and ability to relate and reflect are main factors to take into consideration, as well as external circumstances in the patient’s personal, social, or professional life that either support or intervene with treatment.

Different modalities are available. Some are specifically tailored for NPD; others can be useful for some narcissistic patients but not for others.

Psychodynamic and Psychoanalytic Treatment

Psychodynamic Psychotherapy

Psychodynamic psychotherapy has long been considered the main treatment for personality disorders, including NPD.

This modality focuses on processing patterns and content in self-functioning and interpersonal relationships. Avoidance of emotions and experiences, related both to the past as well as the present, are also attended to. The psychodynamic approach uses exploration of the therapeutic relationship as well as of fantasies, dreams, and wishful thinking to promote change in the patient’s way of thinking and relating.

Transference-Focused Psychotherapy for NPD

Transference-focused psychotherapy for NPD, TFP-N, is an object-relation focused treatment that attends to the patient’s identity diffusion by promoting self-reflective ability, perspective-taking, and emotion tolerance and regulation.

More specifically, it attends to the patients’ narcissistic defensiveness, underlying aggression, enactment of entitlement and grandiosity, and sensitivity to envy, humiliation, shame, and inferiority.

With an exploratory focus on patients’ internal states and behavior, TFP uses clarification, confrontation, and interpretations as prime techniques. The focus is on the interaction between the therapist and the patient, and both transference and countertransference are attended to and integrated in the therapeutic process.

The strategy is flexible and adaptable to the range and level of narcissistic pathology, using a less interpretive technique with patients with more brittle personality structure.

Mentalization-Based Treatment

Mentalization-based treatment, MBT, aims at improving the patient’s reflective capability, i.e., the understanding of own and others’ mental states, including thoughts, attitudes, emotions, and intentions.

Studies have shown that such reflective or mentalizing capacity can improve pathological personality functioning, in particular rigid, inflexible states of mind, and disconnect from own genuine thoughts and experiences.

Adjusted to NPD, this modality aims at engaging the patient’s curiosity, flexibility, and resilience in elaborating on and understanding self and others, especially in interpersonal situations that are experienced as stressful or challenging.

Using a more supportive, validating, exploratory, and accepting non-authoritative therapeutic approach, this modality can improve self-esteem regulation, reactivity, and interpersonal relatedness.

Clarification-Oriented Psychotherapy

Clarification-oriented psychotherapy, COP, focuses on self-regulation and motivation in the patient’s interpersonal interactions and relationships.

By differentiating the patient’s authentic motives from strategic interactional maneuvers, this modality helps the patient identify interpersonal problems and dissatisfactions.

Exploration of specific situations increases the patient’s awareness of internal needs, motives, assumptions, and affects, especially those related to shame and anger, which motivate interpersonal compensatory maneuvering.

Clarification and processing of dysfunctional schemas can lead to new authentic behavior and compassion towards self and others.

Intensive Psychoanalytic Psychotherapy

Intensive psychoanalytic psychotherapy with two or three weekly sessions is indicated when patients have more severe narcissistic symptoms or experience acute consequences of their symptoms.

It is appropriate for patients who can benefit from an active and interactive exploratory approach, and for whom face-to-face interaction and eye-contact is important to counterbalance detachment and emotional disengagement.


Psychoanalysis with three to five sessions per week over several years is recommended for motivated and higher functioning patients with pathological narcissism or NPD, with good capacity for free associations, insight, and interpersonal relatedness, and with high affect sensitivity and tolerance.

Cognitive-Behavioral Treatment

Schema-Focused Therapy

Schema-focused therapy for NPD combines cognitive, behavioral, experiential, and transference-based techniques to work with schema modes. The treatment focuses on changing the patient’s intimate relationships, including both the relationship to the therapist as well as other significant relationships.

The goal of the treatment is to promote a healthy adult mode by helping the patient repair and regulate significant narcissistic moods.

General cognitive and behavioral strategies combined with empathic confrontation and homework assignments are used to address typical narcissistic cognitive distortions such as “black-or-white” thinking, being devalued and deprived by others, and perfectionism.

Metacognitive Interpersonal Therapy

Metacognitive interpersonal therapy, MIT, a manualized step-by-step treatment for NPD, begins with an autobiographical mode to achieve a shared understanding of the patients’ problems, and then promotes recognition and awareness of their functioning and mental states, interpersonal relationship schemas, and indications of poor agency and acting.

Change is achieved through support of reality and perspective-taking, and by identifying normal grandiosity, stimulating a critical distance to old behavior, and building new schemas for thinking, feeling, and interpersonal relationships that promote agency and autonomy.

Cognitive Behavior Therapy

Cognitive behavior therapy, CBT, largely designed for patients with BPD, can be beneficial for some patients with pathological narcissism and NPD who are more behaviorally and action-oriented and need to gain control of thoughts and behavior.

Three strategies, i.e., psychoeducation, validation, and identifying “target behaviors” can be useful, especially in conjunction with psychodynamic psychotherapy as part of a multimodal treatment plan.

Note that some people with pathological narcissism and NPD may find these strategies too superficial, target-oriented, or even threatening and intrusive, and react with protesting, rebelling, or premature termination.

Dialectical Behavior Therapy

Dialectical behavior therapy, DBT, originally invented for patients with BPD, incorporates validation as an important therapeutic tool to promote self-identification and acceptance and potentially help to reduce feelings of shame, self-criticism, and self-blame.

Agreed upon symptoms or “target behaviors” are specifically attended to via a weekly scorecard that can provide clear evidence of progress of change.

Skills focusing on emotion regulation and distress tolerance can be beneficial for patients with NPD. While DBT can be very challenging for some patients with NPD, for others the exploratory and skill-focused work can provide clear indications of problems and progress, and hence support the patient’s sense of internal control and self-agency.

Learn more about dialectical behavior therapy

Additional Treatment Modalities

General psychiatric management for NPD, GPM-N, uses a pragmatic approach to facilitate functioning and self-esteem regulation in patients with NPD. It relies on relationship management, psychoeducation, and negotiation of goals.

The advantages of this approach include flexibility, openness to inclusion of other treatment modalities, ease of learning, and relatively low intensity of treatment.

Psychoeducation, adapted from principles for DBT, can improve the understanding of motivational incentives and of emotional and intrapsychic experiences. This can strengthen narcissistic patients’ sense of internal control and agency, and decrease avoidance, fear of the unknown, of loss of control, and of incomprehensible feelings and mental processes.

This can also help to support the patients’ motivation and courage to further engage in treatment, to understand the purpose, and to explore deeper emotions and conflicts.

Couples therapy has proved to be increasingly useful as narcissistic problems often occur and escalate in the relationship between spouses.

The advantage of including different perspectives and opportunity for chain analysis and promoting understanding of reactions can lead to both acceptance and change. Nevertheless, the discrepancies, rage, and discontent between spouses can be challenging.

Group therapy can, in conjunction with individual treatment, provide exposure activating and corrective opportunities for identifying and addressing shame, self-sufficiency, dependency, non-relatedness, and narcissistic fantasies.

The group setting can gradually challenge and stimulate interaction with others and provide opportunities to learn and practice self-tolerance. The balance between individual and group interests can be difficult for the patients as well as for the group leader.

Psychopharmacological treatment can be beneficial for a comorbid Axis I disorder, such as bipolar disorder, major depression, or anxiety disorder. Of importance is that these patients’ hypersensitivity to side effects, especially those affecting their sexual and intellectual functioning, can contribute to their non-compliance or refusal of such treatment.

No specific pharmacotherapy has proved to be effective for pathological narcissism and NPD.


Narcissism and its related pathology have received increasing social attention mainly because of its self-enhancing and interpersonally provocative patterns, and its organizational and societal consequences.

Significant negative attitudes and stigmatization of this mental condition have unfortunately developed. However, thanks to increasing clinical and empirical attention to pathological narcissism and NPD, our knowledge and understanding of the individual behind the diagnosis are changing.

The co-occurrence and interaction between consistent and deliberate overt self-enhanced functioning and covert internal vulnerability and suffering have been verified in clinical as well as empirical studies. Recent neuroscientific studies have also added to our understanding of underlying patterns or deficits that contribute to narcissistic vigilance and reactivity.

Most people with NPD struggle with fluctuating self-esteem, including both self-enhancement/grandiosity and vulnerability/inferiority.

Similarly, empathic ability is present but compromised and fluctuating. The new dimensional trait focused approach to diagnosing personality disorders can also capture more clinically relevant psychological features and patterns beyond the typical external functioning.

It is important to assess and attend to narcissism as a spectrum of personality functioning that occurs in different contexts and stages in life.

A useful differentiation can be between:

  1. Exaggerated narcissism in specific situations or life contexts,
  2. Consistent narcissistic personality style without narcissistic pathology,
  3. Pathological narcissism with different degrees of severity that occur intermittently or steadily in specific contexts,
  4. NPD meeting the full diagnostic outline of personality functioning with traits or criteria in accordance with DSM-5,
  5. NPD with co-morbid conditions, such as mood disorder, post-traumatic stress disorder, or substance misuse disorder, or immoral or antisocial behavior.

More effective treatment strategies are gradually developing that focus on alliance building, understanding the complex co-occurrence and interactions between self-enhancing grandiosity and self-depleting vulnerability, and between cognitive and emotional narcissistic personality functioning, as well as on the patient’s life or interpersonal contexts.

Increased societal awareness about the nature of narcissism, and the complexity of pathological narcissism and NPD is a work in progress that hopefully will help to reduce misunderstandings, condemnation, and prejudice, and make treatment for patients struggling with these conditions more available and effective.

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Looking for Additional Information?

Literature on Theory, Research, Diagnosis, and Treatment of NPD

Treating Pathological Narcissism With Transference Focused Psychotherapy
by Diana Diamond, Frank E. Yeomans, Barry L. Stern, and Otto F. Kernberg
(Guilford Press, 2021)

The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments
edited by W. Keith Campbell, Joshua D. Miller
(John Wiley & Sons, Inc., 2011)

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
(American Psychiatric Association, 2013)

Understanding and Treating Pathological Narcissism
edited by John S. Ogrodniczuk, PhD
(American Psychological Association, 2013)

Narcissistic Patients and New Therapists: Conceptualization, Treatment and Managing Countertransference
edited by Steven K. Huprich
(Rowman and Littlefield, 2008)

The Productive Narcissist. The Promise and Peril of Visionary Leadership
by Michael Maccoby
(Broadway Books, 2007)

Identifying and Understanding the Narcissistic Personality
by Elsa F. Ronningstam
(Oxford University Press, 2005)

Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications
edited by Elsa F. Ronningstam
(Jason Aronson, 2000)

Guide Books

Children of the Self-Absorbed: A Grown-Up’s Guide to Getting Over Narcissistic Parents, 3rd edition
by Nina W. Brown
(New Harbinger Publications, 2020)

Loving the Self-Absorbed: How to Create a More Satisfying Relationship With a Narcissistic Partner
by Nina W. Brown
(New Harbinger Publications, 2003)

Movies Characterizing Narcissistic Personalities

Many movies advertised to capture narcissistic personalities or people with pathological narcissistic personality functioning often highlight striking and sometimes overly exaggerated features and interpersonal patterns

American movies:

  • Gaslight – Charles Boyer, Ingrid Bergman
  • All That Jazz – Roy Scheider
  • American Psycho – Christian Bale
  • The Door in the Floor – Jeff Bridges
  • Rick – Bill Pullman, Aron Stanford
  • Shock to the System – Michael Caine
  • The Devil Wears Prada – Meryl Streep
  • Mommie Dearest – Faye Dunaway
  • White Oleander – Michelle Pfeiffer
  • Gone With the Wind – Vivien Leigh
  • Fatal Attraction – Michael Douglas, Glenn Close, Anne Archer
  • The Rain Man – Tom Cruise, Dustin Hoffman
  • Stardust Memories – Woody Allen, Charlotte Rampling
  • Ordinary People – Donald Sutherland, Mary Tyler Moore
  • Black Swan – Natalie Portman, Vincent Cassel
  • Harry Potter and the Chamber of Secrets – Daniel Radcliffe, Rupert Grint
  • Blue Jasmine – Cate Blanchett, Alec Baldwin
  • Wall Street – Michael Douglas, Charlie Sheen
  • The Mosquito Coast – Harrison Ford

British-American movie:

  • Alfie – Jude Law, 2004

British movies:

  • The Kings Speech – Colin Firth, Geoffrey Rush, Helena Bonham Carter
  • Alfie – Michael Caine, 1966
  • Dorian Grey – Ben Barnes, Colin Firth

Norwegian movie:

  • Headhunters – Aksel Hennie, Synnøve Macody Lund (based on a novel by Jo Nesbø)

French movies:

  • Read My Lips – Emmanuelle Devos and Vincent Cassel,
  • The Piano Teacher – Isabelle Huppert and Benoit Magimel (based on a novel by Elfride Jelinek)

German movie:

  • Mostly Martha by Sandra Nettelbeck, starring Martina Gedach

About Dr. Ronningstam

Elsa Ronningstam, PhD, is an associate professor, part-time, at Harvard Medical School and a clinical psychologist at McLean Hospital, affiliated with the Gunderson Outpatient Program for treatment of personality disorders.