{{pp-pc|small=yes}} {{Short description|Personality disorder}} {{cs1 config|name-list-style=vanc}} {{Use dmy dates|date=March 2020}} {{Infobox medical condition | name = Narcissistic personality disorder | image = Narcissus-Caravaggio (1594-96) edited.jpg | image_size = 150px | caption = [[Narcissus (Caravaggio)|Narcissus]] (1597–1599) by [[Caravaggio]]; the man in love with his own reflection | alt = Painting of Narcissus by Caravaggioq | field = [[Psychiatry]], [[clinical psychology]] | synonyms = | symptoms = [[grandiosity|Exaggerated feelings of self-importance]], excessive craving for [[admiration]], reduced levels of [[empathy]]<ref name=Caligor_2015/><ref name="DSM5">{{Cite book|title=Diagnostic and statistical manual of mental disorders: DSM-5.|date=2013|publisher=[[American Psychiatric Association]]|isbn=978-0-89042-554-1|edition=5th|location=Arlington, Virginia|pages=72–669|oclc=830807378}}</ref> | complications = | onset = Early adulthood<ref name=DSM5/> | duration = Long term<ref name=DSM5/> | causes = A combination of genetic and environmental factors. Social theories of NPD are weak and causality is unclear. | risks = | diagnosis = Based on symptoms | differential = [[Bipolar disorder]], [[mania]] and [[hypomania]], [[antisocial personality disorder]], [[substance abuse]], [[borderline personality disorder]], [[histrionic personality disorder]],<ref name="Caligor_2015"/> [[grandiose delusions]]. | prevention = | treatment = [[Psychotherapy]], pharmaceuticals for [[comorbidity|comorbid]] disorders<ref name="Caligor_2015"/> | medication = | prognosis = | prevalence = 0.5%<ref>{{cite journal |last1=Eaton |first1=Nicholas R. |last2=Greene |first2=Ashley L. |date=2018 |title=Personality disorders: Community prevalence and socio-demographic correlates |journal=Current Opinion in Psychology |volume=21 |issue=1 |pages=14–18 |doi=10.1016/j.copsyc.2017.08.026 |pmid=28918209}}</ref> to 6.2%<ref>{{cite journal | pmc=2669224 | date=2008 | title=Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Narcissistic Personality Disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions | journal=[[The Journal of Clinical Psychiatry]] | publisher=Physicians Postgraduate Press | location=Memphis, Tennessee | volume=69 | issue=7 | pages=1033–1045 | doi=10.4088/jcp.v69n0701 | pmid=18557663 | first1=Frederick S. |last1= Stinson | first2=Deborah A. | last2=Dawson | first3= Risë B. | last3=Goldstein | first4=Patricia S. | last4=Chou | first5= Boji |last5= Huang | first6=Sharon S. | last6=Smith | first7=W. June| last7=Ruan | first8=Attila J. | last8=Pulay | first9=Tulshi D. | last9=Saha | first10=Roger P. | last10=Pickering | first11=Briget F. | last11=Grant }}</ref> | deaths = }}<!-- The content of this section is transcluded to [[Classification of personality disorders#Cluster B]]. Please be aware that changes made to the original source here will affect the transcluded version on the target page mentioned. -->{{Personality disorders sidebar}}
'''Narcissistic personality disorder''' ('''NPD''') is <noinclude>a complex and [[Heterogeneous condition|heterogeneous]] [[personality disorder]] </noinclude>characterized by patterns of [[grandiosity]], [[Entitlement (psychology)|entitlement]], low empathy, and interpersonal difficulties, which can manifest as either grandiose ("thick-skinned") or vulnerable ("thin-skinned") forms.<ref name=Caligor_2015/><ref name=DSM5/> Grandiose individuals display [[Hubris|arrogance]], [[Social dominance orientation|social dominance]], and exploitative behaviors, while vulnerable individuals show shame, [[inferiority]], [[Sensory processing sensitivity|hypersensitivity]], and extreme reactions to criticism. NPD often involves impaired emotional empathy, superficial relationships, and difficulty tolerating disagreement.<noinclude> It is often co-morbid with other mental disorders and associated with significant functional impairment and [[psychosocial]] [[disability]].<ref name="Caligor_2015" /> </noinclude>
Criteria for diagnosing narcissistic personality disorder are listed in the [[American Psychiatric Association]]'s ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (DSM), while the ''[[International Statistical Classification of Diseases and Related Health Problems|International Classification of Diseases]]'' (ICD) contains criteria only for a general ''personality disorder'' since the introduction of the latest edition.
There is no standard treatment for NPD.<ref name="Mitra_2022">{{cite book | first1 = Paroma | last1 = Mitra | first2 = Tyler J. | last2 = Torrico | first3=Dimy | last3=Fluyau | chapter = Narcissistic Personality Disorder |date=2022 | chapter-url = https://www.ncbi.nlm.nih.gov/books/NBK556001/ | title = StatPearls |location=Treasure Island, Florida|publisher=StatPearls Publishing |pmid=32310461 }}</ref><ref name="King_2020">{{Cite journal | vauthors = King RM, Grenyer BF, Gurtman CG, Younan R |date=March 1, 2020 |title=A clinician's quick guide to evidence-based approaches: Narcissistic personality disorder |journal=[[Clinical Psychologist]]|publisher=[[Australian Psychological Society]]|location=Melbourne, Australia|volume=24 |issue=1 |pages=91–95 |doi=10.1111/cp.12214 |hdl=10536/DRO/DU:30136767 |s2cid=216198008 |issn=1328-4207|hdl-access=free }}</ref> Its high comorbidity with other mental disorders influences treatment and outcomes.<ref name="Mitra_2022" /> [[Psychotherapy|Psychotherapeutic]] treatments generally fall into two categories: [[Psychoanalysis|psychoanalytic]]/[[Psychodynamic psychotherapy|psychodynamic]] and [[cognitive behavioral therapy]], with growing support for integration of both in therapy.<ref name="Yakeley_2018">{{Cite journal | vauthors = Yakeley J |date=July 5, 2018 |title=Current understanding of narcissism and narcissistic personality disorder |journal=BJPsych Advances |volume=24 |issue=5 |pages=305–315 |doi=10.1192/bja.2018.20 |s2cid=148566892 |issn=2056-4678|doi-access=free }}</ref><ref name=":Ronningstam_2016">{{cite journal | vauthors = Weinberg I, Ronningstam E | title = Dos and Don'ts in Treatments of Patients With Narcissistic Personality Disorder | journal = Journal of Personality Disorders | volume = 34 | issue = Suppl | pages = 122–142 | date = March 2020 | pmid = 32186986 | doi = 10.1521/pedi.2020.34.supp.122 | publisher = [[Guilford Press]] | s2cid = 214583609 }}</ref> However, there are few studies on the effectiveness of treatments.<ref name="King_2020" /> Treatment is frequently not sought; one's subjective experience of the mental disorder, as well as one's agreement to and level of engagement with treatment, are highly dependent on one's motivation to change.<ref>{{Cite book |title=Personality Disorders and Pathology: Integrating Clinical Assessment and Practice in the DSM-5 and ICD-11 Era |date=2022 |publisher=American Psychological Association |jstor=j.ctv2h43b0f |isbn=978-1-4338-3576-6}}</ref>
NPD's [[etiology]] is thought to be largely genetic and neurobiological, with structural and functional brain differences in areas related to self-processing and empathy. Assessment tools such as the [[Narcissistic Personality Inventory]] or Pathological Narcissism Inventory can help differentiate subtypes. NPD has historical roots in [[psychoanalytic theory]] and remains a subject of controversy in psychiatric classification, while its manifestations continue to appear in literature and media as exemplars of extreme self-focus and entitlement.
==Signs and symptoms== <blockquote>Individuals with narcissistic personality disorder may be grandiose or self-loathing, extraverted or socially isolated, captains of industry or unable to maintain steady employment, model citizens or prone to antisocial activities.<ref name=":7">{{cite journal|first1=Eve|last1=Caligor|first2=Kenneth N.|last2=Levy|first3=Frank E.|last3=Yeomans|date=May 2015|title=Narcissistic personality disorder: Diagnostic and clinical challenges|journal=[[American Journal of Psychiatry]]|publisher=[[American Psychiatric Association]]|location=Arlington, Virginia|volume=172|issue=5|pages=415–422|doi=10.1176/appi.ajp.2014.14060723 |pmid=25930131 }}</ref> </blockquote>NPD is complex and far from uniform in its presentation and consequences. Empirical evidence suggests several subtypes of NPD may exist (see the Subtypes section below), but in general, the disorder is known to have grandiose ("thick-skinned") and vulnerable ("thin-skinned") expressions.<ref name=":7" />
Grandiose, thick-skinned NPD patients show a sense of uniqueness or superiority, attitudes of entitlement, a belief that others envy their abilities or status, low empathy, social dominance, superficial charm, disdainfulness or snobbery, and an exploitative interpersonal style characterized by manipulation and selfishness.
Vulnerable, thin-skinned individuals with NPD also show entitlement, selfishness and low empathy, but uniquely, they demonstrate feelings of shame and inferiority, are envious of others' abilities or status, tend to be shy, paranoid, vindictive, and emotionally dependent on admiration, and show extreme rage and hostility in response to rejection and criticism.<ref name="Kramer_2018">{{cite journal | vauthors = Kramer U, Pascual-Leone A, Rohde KB, Sachse R | title = The role of shame and self-compassion in psychotherapy for narcissistic personality disorder: An exploratory study | journal = Clinical Psychology & Psychotherapy | volume = 25 | issue = 2 | pages = 272–282 | date = March 2018 | pmid = 29265698 | doi = 10.1002/cpp.2160 | url = https://serval.unil.ch/resource/serval:BIB_EFC9C7A83CF6.P001/REF.pdf }}</ref> This behavior stems from low-self esteem, a need for admiration and validation, and social belonging (Mitra et al., 2024).
While vulnerable-type patients typically show extreme distress and dysfunction, grandiose variants tend to be associated with ''greater'' psychological wellbeing,<ref name="Tanzilli_202022">{{cite journal |vauthors=Tanzilli A, Gualco I |date=March 2020 |title=Clinician Emotional Responses and Therapeutic Alliance When Treating Adolescent Patients With Narcissistic Personality Disorder Subtypes: A Clinically Meaningful Empirical Investigation |journal=Journal of Personality Disorders |volume=34 |issue=Suppl |pages=42–62 |doi=10.1521/pedi.2020.34.supp.42 |pmid=32186983 |s2cid=213186868}}</ref><ref>{{cite journal|first1=Constantine|last1=Sedikides|first2=Yixin|last2=Tang|first3=Yan|last3=Liu|first4=Eva|last4=de Boer|date=December 2024|title=Narcissism and Wellbeing: A Cross-Cultural Meta-Analysis|journal=[[Personality and Social Psychology Bulletin]]|volume=52 |issue=5 |article-number=01461672241307531 |publisher=[[Sage Publications]]|location=Thousand Oaks, California|doi=10.1177/01461672241307531 |pmid=39921533 |doi-access=free |pmc=13022027 }}</ref> often manifesting dysfunction by occupational conflict, harming others, antisocial behavior or emotional strain resulting from perfectionism.<ref name=":7" /><ref name="Tanzilli_202022" /><ref>Miller, J. D., Campbell, W. K., & Pilkonis, P. A. (2007). Narcissistic personality disorder: Relations with distress and functional impairment. ''Comprehensive psychiatry'', ''48''(2), 170-177.</ref><ref name="Russ_200822"/>
It is often theorized that some patients may oscillate between grandiosity and vulnerability.<ref name=":8">Gore, W. L., & Widiger, T. A. (2016). Fluctuation between grandiose and vulnerable narcissism. ''Personality Disorders: Theory, Research, and Treatment'', ''7''(4), 363.</ref> While some evidence suggests that grandiose individuals show occasional reactive anger (a vulnerable trait), but narcissistically vulnerable individuals do not show signs of grandiosity,<ref name=":8" /><ref>Edershile, E. A., & Wright, A. G. (2021). Fluctuations in grandiose and vulnerable narcissistic states: A momentary perspective. ''Journal of Personality and Social Psychology'', ''120''(5), 1386.</ref> most studies show the vulnerable individuals show occasional bouts of [[grandiosity]], narcissistically grandiose individuals show few or no signs of vulnerability.<ref>Edershile, E. A., Oltmanns, J. R., Widiger, T. A., & Wright, A. G. (2021). Predicting fluctuation in narcissistic states: An examination of the g-FLUX scale. ''Psychological assessment'', ''33''(1), 60.</ref><ref>Oltmanns, J. R., & Widiger, T. A. (2018). Assessment of fluctuation between grandiose and vulnerable narcissism: Development and initial validation of the FLUX scales. ''Psychological Assessment'', ''30''(12), 1612.</ref><ref>Henttonen, P., Salmi, J., Peräkylä, A., & Krusemark, E. A. (2022). Grandiosity, vulnerability, and narcissistic fluctuation: Examining reliability, measurement invariance, and construct validity of four brief narcissism measures. ''Frontiers in psychology'', ''13'', 993663.</ref><ref>Di Sarno, M., Madeddu, F., & Di Pierro, R. (2023). Clustering daily expressions of grandiose and vulnerable narcissism. ''Journal of Social and Clinical Psychology'', ''42''(5), 452-470.</ref>
===Other features=== NPD patients may have difficulty accepting help.<ref>{{cite journal | vauthors = Kacel EL, Ennis N, Pereira DB | title = Narcissistic Personality Disorder in Clinical Health Psychology Practice: Case Studies of Comorbid Psychological Distress and Life-Limiting Illness | journal = Behavioral Medicine | date = 2017 | volume = 43 | issue = 3 | pages = 156–164 | doi = 10.1080/08964289.2017.1301875 | pmid = 28767013 | pmc = 5819598 }}</ref> They may also exhibit [[Revenge|vengeful fantasies]],<ref name="Narcissistic Personality Disorder a">{{cite journal |display-authors=6 |vauthors=Coleman D, Lawrence R, Parekh A, Galfalvy H, Blasco-Fontecilla H, Brent DA, Mann JJ, Baca-Garcia E, Oquendo MA |date=February 2017 |title=Narcissistic Personality Disorder and suicidal behavior in mood disorders |journal=Journal of Psychiatric Research |volume=85 |pages=24–28 |doi=10.1016/j.jpsychires.2016.10.020 |pmc=5191918 |pmid=27816770}}</ref><ref name=asrotr>{{Cite journal | vauthors = Lowenstein J, Purvis C, Rose K | title = A systematic review on the relationship between antisocial, borderline and narcissistic personality disorder diagnostic traits and risk of violence to others in a clinical and forensic sample | journal = Borderline Personality Disorder and Emotion Dysregulation | date = October 13, 2016 | volume = 3 | article-number= 14 | doi = 10.1186/s40479-016-0046-0 | pmid = 27777779 | pmc = 5062934 | doi-access = free }}</ref> as well as violent and antisocial behaviour.<ref>Du, T. V., Miller, J. D., & Lynam, D. R. (2022). The relation between narcissism and aggression: A meta‐analysis. ''Journal of personality'', ''90''(4), 574-594.</ref><ref name="Russ_200822" /> They are more likely to try forms of [[plastic surgery]] due to a desire to gain attention and to be seen as beautiful.<ref>{{cite journal | vauthors = Loron AM, Ghaffari A, Poursafargholi N | title = Personality Disorders among Individuals Seeking Cosmetic Botulinum Toxin Type A (BoNTA) Injection, a Cross-Sectional Study | journal = The Eurasian Journal of Medicine | volume = 50 | issue = 3 | pages = 164–167 | date = October 2018 | doi = 10.5152/eurasianjmed.2018.17373 | pmid = 30515036 | pmc = 6263231 }}</ref><ref name="ronningstam2016">{{cite journal |vauthors=Ronningstam E |year=2016 |title=New Insights into Narcissistic Personality Disorder |url=http://www.psychiatrictimes.com/special-reports/new-insights-narcissistic-personality-disorder |journal=[[Psychiatric Times]] |location=New York |publisher=MJH Associates |volume=33 |issue=2 |page=11 |access-date=17 August 2018 |archive-date=17 August 2018 |archive-url=https://web.archive.org/web/20180817061541/http://www.psychiatrictimes.com/special-reports/new-insights-narcissistic-personality-disorder }}</ref>
Patients with NPD have an impaired ability to recognize facial expressions or mimic emotions, as well as a lower capacity for [[Empathy|emotional empathy]] and [[emotional intelligence]]<ref>{{cite journal | vauthors = Ronningstam E | title = Internal Processing in Patients With Pathological Narcissism or Narcissistic Personality Disorder: Implications for Alliance Building and Therapeutic Strategies | journal = Journal of Personality Disorders | volume = 34 | issue = Suppl | pages = 80–103 | date = March 2020 | doi = 10.1521/pedi.2020.34.supp.80 | pmid = 32186980 | s2cid = 213181317 }}</ref><ref name="pmid30210418">{{cite journal | vauthors = Zajenkowski M, Maciantowicz O, Szymaniak K, Urban P | title = Vulnerable and Grandiose Narcissism Are Differentially Associated With Ability and Trait Emotional Intelligence | journal = Frontiers in Psychology | volume = 9 | issue = | article-number= 1606 | date = 2018 | pmid = 30210418 | pmc = 6120976 | doi = 10.3389/fpsyg.2018.01606 | doi-access = free }}</ref> but preserved capacity for cognitive empathy or an impaired [[theory of mind]].<ref>{{Cite journal | vauthors = Eddy CM |date=2021-05-01 |title=Self-serving social strategies: A systematic review of social cognition in narcissism |journal=Current Psychology |volume=42 |issue=6 |pages=4362–4380 |language=en |doi=10.1007/s12144-021-01661-3 |s2cid=235587088 |issn=1936-4733|doi-access=free }}</ref> People with NPD are less likely to engage in [[prosocial behavior]].<ref name="pmid24512457">{{cite journal |vauthors=Baskin-Sommers A, Krusemark E, Ronningstam E |date=July 2014 |title=Empathy in narcissistic personality disorder: from clinical and empirical perspectives |journal=Personality Disorders |volume=5 |issue=3 |pages=323–333 |doi=10.1037/per0000061 |pmc=4415495 |pmid=24512457}}</ref> They can still act in selfless ways to improve others' perceptions of them, advance their [[social status]], or if explicitly told to.<ref name="pmid34461435">{{cite journal | vauthors = Stolz DS, Vater A, Schott BH, Roepke S, Paulus FM, Krach S | title = Reduced frontal cortical tracking of conflict between self-beneficial versus prosocial motives in Narcissistic Personality Disorder | journal = NeuroImage. Clinical | volume = 32 | issue = | article-number= 102800 | date = 2021 | pmid = 34461435 | pmc = 8405953 | doi = 10.1016/j.nicl.2021.102800 }}</ref> Despite these characteristics, they are more likely to overestimate their capacity for empathy.<ref name="pmid21055831">{{cite journal | vauthors = Ritter K, Dziobek I, Preissler S, Rüter A, Vater A, Fydrich T, Lammers CH, Heekeren HR, Roepke S | display-authors = 6 | title = Lack of empathy in patients with narcissistic personality disorder | journal = Psychiatry Research | volume = 187 | issue = 1–2 | pages = 241–247 | date = May 2011 | pmid = 21055831 | doi = 10.1016/j.psychres.2010.09.013 | s2cid = 7718348 }}</ref> Recent work, however, suggests narcissistic empathy deficits may be resolved (at least in part) by instructed perspective-taking.<ref>Hart, C. M., Hepper, E. G., & Sedikides, C. (2018). Understanding and mitigating narcissists' low empathy. ''Handbook of trait narcissism: Key advances, research methods, and controversies'', 335-343.</ref>
It is common for people with NPD to have difficult relationships.<ref name="Gewirtz-Meydan_2018">{{Cite journal | vauthors = Gewirtz-Meydan A, Finzi-Dottan R |date = April 2018 |title=Narcissism and Relationship Satisfaction from a Dyadic Perspective: The Mediating Role of Psychological Aggression |journal=Marriage & Family Review |language=en |volume=54 |issue=3 |pages=296–312 |doi=10.1080/01494929.2017.1359814 |issn=0149-4929 |s2cid=148631814}}</ref><ref>{{Cite journal | vauthors = Cramer P |date=October 2010 |title=Narcissism through the ages: What happens when narcissists grow older? |journal=Journal of Research in Personality |language=en |volume=45 |issue=5 |pages=479–492 |doi=10.1016/j.jrp.2011.06.003}}</ref><ref>{{Cite journal | vauthors = Mathieu C |date=October 2013 |title=Personality and job satisfaction: The role of narcissism |url=https://linkinghub.elsevier.com/retrieve/pii/S0191886913002298 |journal=Personality and Individual Differences |language=en |volume=55 |issue=6 |pages=650–654 |doi=10.1016/j.paid.2013.05.012|url-access=subscription }}</ref><ref name=naqol>{{Cite journal | vauthors = Ellison WD, Acuff MC, Kealy D, Joyce AS, Ogrodniczuk JS | title = Narcissism and Quality of Life: The Mediating Role of Relationship Patterns | journal = The Journal of Nervous and Mental Disease | volume = 208 | issue = 8 | pages = 613–618 | date = August 2020 | pmid = 32229790 | doi = 10.1097/NMD.0000000000001170 | publisher = [[Lippincott Williams & Wilkins]] | s2cid = 213949270 }}</ref> They may disrespect others' boundaries or [[Idealization and devaluation|idealize and devalue]] them. They commonly keep people emotionally distant, and [[Psychological projection|project]], deny,<ref>{{cite journal | vauthors = Di Pierro R, Costantini G, Benzi IM, Madeddu F, Preti E | title = Grandiose and entitled, but still fragile: A network analysis of pathological narcissistic traits. | journal = Personality and Individual Differences | date = April 2019 | volume = 140 | pages = 15–20 | doi = 10.1016/j.paid.2018.04.003 | s2cid = 149618835 }}</ref> or [[Splitting (psychology)|split]]. NPD individuals manifesting vulnerability tend to become enraged when rejected or criticised,<ref name="Gewirtz-Meydan_2018" /><ref name=naqol/><ref name="pmid24007215">{{cite journal | vauthors = Barry CT, Kauten RL | title = Nonpathological and pathological narcissism: which self-reported characteristics are most problematic in adolescents? | journal = Journal of Personality Assessment | volume = 96 | issue = 2 | pages = 212–219 | date = 2014 | pmid = 24007215 | doi = 10.1080/00223891.2013.830264 | s2cid = 23508050 }}</ref> and may degrade, insult, or blame others who disagree with them.<ref>{{Cite book | vauthors = Ronningstam E |title=Identifying and understanding the narcissistic personality |date=2005 |publisher=[[Oxford University Press]] |isbn=978-0-19-803396-7 |location=New York |pages=22–27 |oclc=61329826}}</ref><ref>{{Cite web |title=Understanding Relational Dysfunction in Borderline, Narcissistic, and Antisocial Personality Disorders: Clinical Considerations, Presentation of Three Case Studies, and Implications for Therapeutic Intervention |url=http://www.davidpublisher.com/index.php/Home/Article/index?id=41668.html |access-date=2022-07-20 |website=www.davidpublisher.com}}</ref>
NPD may be associated with reduced insight into symptoms, especially in severe cases.<ref>{{cite journal | vauthors = Cooper LD, Balsis S, Oltmanns TF | title = Self- and informant-reported perspectives on symptoms of narcissistic personality disorder | journal = Personality Disorders | volume = 3 | issue = 2 | pages = 140–154 | date = April 2012 | doi = 10.1037/a0026576 | pmid = 22452774 | pmc = 3396740 }}</ref> However, work on lower levels of narcissism suggests such individuals are not only aware of their traits but see them in a positive light, and strive to maintain them over time.<ref>Carlson, E. N., & Khafagy, R. (2018). What do narcissists know about themselves? Exploring the bright spots and blind spots of narcissists' self-knowledge. ''Handbook of Trait Narcissism: Key Advances, Research Methods, and Controversies'', 275-282.</ref> Given the high-function sociability associated with [[narcissism]], some people with NPD might not view such a diagnosis as a functional impairment to their lives.<ref name="Ronningstam_2010">{{cite journal |vauthors=Ronningstam E |date=February 2010 |title=Narcissistic personality disorder: a current review |journal=Current Psychiatry Reports |volume=12 |issue=1 |pages=68–75 |doi=10.1007/s11920-009-0084-z |pmid=20425313 |s2cid=19473736}}</ref>
Although overconfidence tends to make people with NPD very ambitious, such a mindset does not necessarily lead to professional high achievement and success, because they refuse to take risks, in order to avoid failure or the appearance of failure.<ref name="DSM5" /><ref name="ronningstam2016" /> Moreover, the psychological inability to tolerate disagreement, contradiction, and criticism makes it difficult for persons with NPD to work cooperatively or to maintain long-term relationships.<ref name="gol2">{{Cite book |url= |title=Trapped in the Mirror: Adult Children of Narcissists in Their Struggle For Self |vauthors=Golomb E |date=1992 |publisher=W. W. Morrow |isbn=0-688-09471-6 |edition=1st |location=New York |oclc=23143624}}{{page needed|date=September 2021}}</ref>
Individuals with NPD often do not practice or believe in harm avoidance. Instead, they view punishment and accountability as inferior and unnecessary, and view consequences with a low regard, regardless of their negative behaviors and actions (Mitra et al., 2024). They have few social inhibitions due to their grandiose personality complex.<ref>{{Cite journal |last1=Kacel |first1=Elizabeth L. |last2=Ennis |first2=Nicole |last3=Pereira |first3=Deidre B. |date=2017 |title=Narcissistic Personality Disorder in Clinical Health Psychology Practice: Case Studies of Comorbid Psychological Distress and Life-Limiting Illness |journal=Behavioral Medicine (Washington, D.C.) |volume=43 |issue=3 |pages=156–164 |doi=10.1080/08964289.2017.1301875 |issn=1940-4026 |pmc=5819598 |pmid=28767013}}</ref>
Regarding novelty seeking, individuals contain an inherent pleasure to perform unusual gestures as an incentive to gain reward and extreme recognition for their gestures (Mitra et al., 2024).<ref>{{Citation |last1=Mitra |first1=Paroma |title=Narcissistic Personality Disorder |date=2026 |work=StatPearls |url=http://www.ncbi.nlm.nih.gov/books/NBK556001/ |access-date=2026-04-14 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=32310461 |last2=Torrico |first2=Tyler J. |last3=Fluyau |first3=Dimy}}</ref>
=== Attachment styles === A meta-analysis of 33 studies examined the relationship between [[Attachment in adults|adult attachment styles]], as conceptualized by Kim Bartholomew and Leonard M. Horowitz (1991) within [[attachment theory]], and narcissistic traits. Results revealed weak positive [[Correlation|correlations]] between narcissism and each insecure attachment style: anxious-preoccupied (r = 0.13), fearful-avoidant (r = 0.11), and dismissive-avoidant (r = 0.06).<ref name=":18">{{Cite journal |last1=Mohay |first1=Jamie |last2=Cheng |first2=Kadie |last3=de la Piedad Garcia |first3=Xochitl |last4=Willis |first4=Megan L. |date=October 2025 |title=The relationship between attachment styles and narcissism: a systematic and meta-analytic review |url= |journal=Personality and Individual Differences |language=en |volume=244 |article-number=113255 |doi=10.1016/j.paid.2025.113255}}</ref>
Vulnerable narcissism was positively associated with all three insecure attachment styles, with the strongest correlation for anxious-preoccupied (r = 0.43) and fearful-avoidant attachment (r = 0.31), and a weak association with dismissive-avoidant attachment (r = 0.15). In contrast, grandiose narcissism was not significantly associated with insecure attachment styles. A very weak but statistically significant positive association was observed with secure attachment (r = 0.06), indicating a negligible relationship overall. These findings suggest that grandiose narcissism may be largely independent of attachment-related processes and may instead be more strongly associated with other developmental factors, such as parental overvaluation.<ref name=":18" />
These findings are consistent with an earlier meta-analysis, which likewise identified the strongest association between pathological narcissism and anxious-preoccupied (also termed anxious-ambivalent) attachment (r = 0.27), although that study did not distinguish between grandiose and vulnerable narcissism.<ref>{{Cite journal |last1=Zhang |first1=Yihan |last2=Zhang |first2=Juan |last3=Wang |first3=Yihui |date=December 2024 |title=The relationship between attachment insecurity and pathological narcissism: A three-level meta-analysis |url= |journal=Journal of Family Theory & Review |language=en |volume=16 |issue=4 |pages=953–977 |doi=10.1111/jftr.12593 |issn=1756-2570}}</ref>
More recent research indicates that some domains of personality pathology may be largely independent of attachment processes. In particular, antagonistic traits (a central component of NPD, resembling the ICD-11 trait domain of [[Dissociality in personality disorder or personality difficulty|Dissociality]]<ref>{{Cite journal |last1=Bach |first1=Bo |last2=Kramer |first2=Ueli |last3=Doering |first3=Stephan |last4=di Giacomo |first4=Ester |last5=Hutsebaut |first5=Joost |last6=Kaera |first6=Andres |last7=De Panfilis |first7=Chiara |last8=Schmahl |first8=Christian |last9=Swales |first9=Michaela |last10=Taubner |first10=Svenja |last11=Renneberg |first11=Babette |date=2022-04-01 |title=The ICD-11 classification of personality disorders: a European perspective on challenges and opportunities |journal=Borderline Personality Disorder and Emotion Dysregulation |language=en |volume=9 |issue=1 |page=12 |doi=10.1186/s40479-022-00182-0 |doi-access=free |issn=2051-6673 |pmc=8973542 |pmid=35361271}}</ref>) appear to show limited overlap with attachment-related dimensions, suggesting that antagonism may not be strongly linked to attachment constructs.<ref>{{Cite journal |last1=Smith |first1=Madison Shea |last2=South |first2=Susan C. |date=October 2023 |title=Investigating a Common Structure of Personality Pathology and Attachment |url= |journal=Clinical Psychological Science |language=en |volume=12 |issue=5 |pages=962–972 |doi=10.1177/21677026231200018 |issn=2167-7026}}</ref>
==Causes==
===Aetiology=== {{See also|Narcissistic parent}} The cause of narcissistic personality disorder (NPD) is unclear, although there is evidence for a strong biological or genetic underpinning.<ref name=":0">{{Cite book |last=Del Giudice |first=Marco |chapter=Personality Disorders |date=2018 |title=Evolutionary Psychopathology - A unified approach |pages=272–284 |editor-last=Del Giudice |editor-first=Marco |url=https://academic.oup.com/book/1052/chapter/138276725 |publisher=Oxford University Press |language=en |doi=10.1093/med-psych/9780190246846.003.0012 |isbn=978-0-19-024684-6 |url-access=subscription}}</ref><ref name=":2">{{Cite book |last1=Luo |first1=Yu L. L. |title=Handbook of Trait Narcissism |date=2018 |page=150 |editor-last=Hermann |editor-first=Anthony D. |chapter-url=https://rdcu.be/dKfyO |access-date=2024-06-08 |place=Cham |publisher=Springer International Publishing |language=en |doi=10.1007/978-3-319-92171-6_16 |isbn=978-3-319-92170-9 |last2=Cai |first2=Huajian |chapter=The Etiology of Narcissism: A Review of Behavioral Genetic Studies |editor2-last=Brunell |editor2-first=Amy B. |editor3-last=Foster |editor3-first=Joshua D. |chapter-url-access=limited}}</ref><ref name="Paris_2012">{{cite journal |vauthors=Torgersen S, Myers J, Reichborn-Kjennerud T, Røysamb E, Kubarych TS, Kendler KS |date=December 2012 |title=The heritability of Cluster B personality disorders assessed both by personal interview and questionnaire |journal=Journal of Personality Disorders |publisher=[[Guilford Press]] |volume=26 |issue=6 |pages=848–866 |doi=10.1521/pedi_2012_26_060 |pmc=3606922 |pmid=23281671}}</ref><ref>{{cite journal |vauthors=Reichborn-Kjennerud T |date=1 March 2010 |title=The genetic epidemiology of personality disorders |journal=Dialogues in Clinical Neuroscience |publisher=[[Taylor & Francis]] |volume=12 |issue=1 |pages=103–114 |doi=10.31887/DCNS.2010.12.1/trkjennerud |pmc=3181941 |pmid=20373672}}</ref> It is unclear if or how much a person's upbringing contributes to the development of NPD, although many speculative theories have been proposed.<ref name=":0" /><ref name=":1">{{Cite book |url= |title=Gabbard's treatments of psychiatric disorders |vauthors=Gabbard GO |date=2014 |publisher=[[American Psychiatric Association]] |isbn=978-1-58562-442-3 |edition=Fifth/DSM-5 |location=Washington, D.C. |doi=10.1176/appi.books.9781585625048.gg72 |oclc=872383308 }}</ref><ref>{{Cite journal |last=Paris |first=Joel |date=2014 |title=Modernity and narcissistic personality disorder. |url=https://doi.apa.org/doi/10.1037/a0028580 |journal=Personality Disorders: Theory, Research, and Treatment |language=en |volume=5 |issue=2 |pages=220–226 |doi=10.1037/a0028580 |issn=1949-2723 |pmid=22800179 |url-access=subscription}}</ref><ref name=":4">{{Cite journal |last=Torgersen |first=Svenn |date=2009 |title=The nature (and nurture) of personality disorders |journal=Scandinavian Journal of Psychology |language=en |volume=50 |issue=6 |pages=624–632 |doi=10.1111/j.1467-9450.2009.00788.x |issn=0036-5564 |pmid=19930262 |doi-access=free}}</ref>
Evidence to support social factors in the development of NPD is limited.<ref name=":0" /><ref name=":4" /> Some studies have found NPD correlates with permissive and overindulgent parenting in childhood, excessive criticism from parenting. Others have found correlations with harsh discipline, neglect or abuse.<ref name=":0" /> Findings have been inconsistent, and scientists do not know if these correlations are [[Causality|causal]], as these studies do not control for genetic [[confounding]].<ref name=":0" /><ref name=":4" /> According to Ross et al., (2024), if an individual was to experience four or more adverse childhood experiences, there is a stronger likelihood of the development of various personality disorders, such as narcissistic personality disorder. Excessive criticism and parental overpraising were found to be common additional risk factors associated with narcissistic personality disorder.
This problem of genetic confounding is explained by psychologist [[Svenn Torgersen]] in a 2009 review:<ref name=":4" />
{{Blockquote|text=If parents treat their children badly, and the children develop personality disorders, it does not necessarily mean that the treatment of the children is the cause of the development. An alternative explanation may be that the parents themselves have some personality disorder traits, partly due to genes. These genetically influenced traits correlate with poor parenting, explaining the genetic influence on parenting. The children inherit the genes and subsequently develop personality disorders. The personality disorders might thus have developed in any case, independent of the childhood conditions.<ref name=":4" />}}
Twin studies allow scientists to assess the influence of genes and environment, in particular, how much of the variation in a trait is attributed to the "shared environment" (influences shared by twins, such as parents and upbringing) or the "unshared environment" (measurement error, noise, differing illnesses between twins, randomness in brain growth, and social or non-social experiences that only one twin experienced).<ref>{{Cite book |last=Del Giudice |first=Marco |chapter=Individual and Sex Differences |date=2018 |title=Evolutionary Psychopathology: A Unified Approach |pages=68–94 |editor-last=Del Giudice |editor-first=Marco |url=https://academic.oup.com/book/1052/chapter/138261824 |access-date=2024-06-08 |publisher=Oxford University Press |language=en |doi=10.1093/med-psych/9780190246846.003.0003 |isbn=978-0-19-024684-6 |url-access=subscription}}</ref><ref name=":3">{{Cite book |last=Mitchell |first=Kevin J. |title=Innate: how the wiring of our brains shapes who we are |date=2018 |publisher=Princeton University Press |isbn=978-0-691-17388-7 |location=Princeton |pages=54, 84–86}}</ref><ref name=":4" /> According to a 2018 review, twin studies of NPD have found little or no influence from the shared environment, and a major contribution of genes and the non-shared environment:<ref name=":2" />
{{Blockquote|text=Taken together, these studies have consistently demonstrated that genetic influence constitutes a major source of NPD. Non-shared environments also exert substantial influence on NPD. Notably, shared environments had no significant influence on NPD in any of these studies. |author=Lu & Cai, 2018<ref name=":2" />}}
According to neurogeneticist Kevin Mitchell, a lack of influence from the shared environment indicates that the non-shared environmental influence may be largely non-social, perhaps reflecting innate processes such as randomness in brain growth.<ref name=":3" />
===Pathophysiology=== Neuroscientists have also studied the brains of people with NPD using structural imaging technology.<ref name=":5">{{Cite journal |last1=Jauk |first1=Emanuel |last2=Kanske |first2=Philipp |date=2021 |title=Can neuroscience help to understand narcissism? A systematic review of an emerging field |journal=Personality Neuroscience |volume=4 |doi=10.1017/pen.2021.1 |issn=2513-9886 |pmc=8170532 |pmid=34124536 |article-number=e3}}</ref> A 2021 review concluded the most consistent finding among NPD patients is lowered gray matter volume in the [[medial prefrontal cortex]], previously associated with self-enhancement tendencies.<ref name=":5" /> Studies of the occurrence of narcissistic personality disorder identified structural abnormalities in the brains of people with NPD, specifically, a lesser volume of [[gray matter]] in the left, anterior [[insular cortex]].<ref name="Schulze">{{cite journal |display-authors=6 |author2-link=Isabel Dziobek |vauthors=Schulze L, Dziobek I, Vater A, Heekeren HR, Bajbouj M, Renneberg B, Heuser I, Roepke S |date=October 2013 |title=Gray matter abnormalities in patients with narcissistic personality disorder |journal=Journal of Psychiatric Research |publisher=[[Elsevier]] |volume=47 |issue=10 |pages=1363–1369 |doi=10.1016/j.jpsychires.2013.05.017 |pmid=23777939}}</ref> The results of a 2015 study associated the condition of NPD with a reduced volume of gray matter in the [[prefrontal cortex]].<ref>{{cite journal |vauthors=Nenadic I, Güllmar D, Dietzek M, Langbein K, Steinke J, Gaser C |date=February 2015 |title=Brain structure in narcissistic personality disorder: a VBM and DTI pilot study |journal=Psychiatry Research |publisher=Elsevier Ireland |volume=231 |issue=2 |pages=184–186 |doi=10.1016/j.pscychresns.2014.11.001 |pmid=25492857 |s2cid=17073607}}</ref> It has been suggested that empathic dysfunction and selfish behaviour in NPD may result from dysfunction in the brain's [[salience network]] (SN; consisting of the anterior insula and cingulate cortices), which switches between internally- and externally-focused cognition, to inhibit the [[default mode network]] (DMN), involved in self-related information-processing, during social interactions resulting in continued self-focus even when interacting with distressed others.<ref>Jankowiak-Siuda, K., & Zajkowski, W. (2013). A neural model of mechanisms of empathy deficits in narcissism. ''Medical science monitor: international medical journal of experimental and clinical research'', ''19'', 934.</ref> Consonantly, excessive selfishness in NPD appears to be related to decreased ability of the cingulate cortex to track motivational conflict between self-gain and other-pain.<ref>Stolz, D. S., Vater, A., Schott, B. H., Roepke, S., Paulus, F. M., & Krach, S. (2021). Reduced frontal cortical tracking of conflict between self-beneficial versus prosocial motives in Narcissistic Personality Disorder. ''NeuroImage: Clinical'', ''32'', 102800.</ref>
Grandiose and vulnerable expressions of NPD appear to relate differently to brain structure and function. Specifically, NPD patients with grandiose features show enhanced while those vulnerable features show reduced local efficiency in the DMN.<ref>Cao, C., Lou, J., & Liu, W. (2022). Local inefficiency of the default mode network in young men with narcissistic personality disorder. ''Neuroscience Letters'', ''784'', 136720.</ref> Vulnerable cases of NPD also appear to show increased [[oxidative stress]].<ref>{{cite journal |last1=Lee |first1=RJ |last2=Gozal |first2=D |last3=Coccaro |first3=EF |last4=Fanning |first4=J |date=March 2020 |title=Narcissistic and Borderline Personality Disorders: Relationship With Oxidative Stress. |journal=Journal of Personality Disorders |volume=34 |issue=Suppl |pages=6–24 |doi=10.1521/pedi.2020.34.supp.6 |pmid=32186978}}</ref>
===Other aspects=== Evolutionary models of NPD have also been proposed.<ref name=":0" /> According to psychologist Marco Del Giudice, [[cluster B]] traits including NPD, predict increased mating success and fertility. NPD could potentially be an adaptive evolutionary phenomenon, though a risky one that can sometimes result in social rejection and failure to reproduce.<ref name=":0" /> Another proposal is that NPD may result from an excess of traits which are only adaptive in moderate amounts (leadership success increases with moderate degrees of narcissism, but declines at the high end of narcissism).<ref name=":0" />
Research on NPD is limited, because patients are hard to recruit for study.<ref name=":5" /> The cause of narcissistic personality disorder requires further research.<ref name=":4" /><ref name=":0" />
==Diagnosis== A diagnosis of NPD, like other personality disorders, is made by a qualified healthcare professional in a clinical interview. Differential diagnosis is used in order to determine whether NPD is the most appropriate diagnosis (Mitra et al., (2024)).{{Medical citation needed|date=August 2025}}
===Classification=== [[Classification of personality disorders]] differs significantly between the two most prominent frameworks for [[classification of mental disorders]], namely: the ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' and the [[International Classification of Diseases]], the most recent editions of which are the [[DSM-5-TR]] and [[ICD-11]], respectively. In the DSM-5, there are two distinct diagnostic models for personality disorder. The classification system in its main body (Section II) is categorical, i.e., personality disorders are putatively distinct entities, whereas the hybrid dimensional–categorical ''[[Alternative DSM-5 model for personality disorders]]'' (AMPD) has been introduced into [[DSM-5#Section III: Emerging measures and models|Section III]].<ref name=":72">{{Cite journal |last=Clark |first=Lee Anna |author-link=Lee Anna Clark |date=2025-05-01 |title=Wherefrom and Whither PD? Recent Developments and Future Possibilities in DSM-5 and ICD-11 Personality Disorder Diagnosis |journal=Current Psychiatry Reports |language=en |volume=27 |issue=5 |pages=267–277 |doi=10.1007/s11920-025-01602-y |issn=1535-1645 |pmc=12003573 |pmid=40108080}} {{Creative Commons text attribution notice|cc=by4|from this source=yes}}</ref><ref name=":9">{{Cite journal |last1=Rodriguez-Seijas |first1=Craig |last2=Ruggero |first2=Camilo |last3=Eaton |first3=Nicholas R. |last4=Krueger |first4=Robert F. |date=2019 |title=The DSM-5 Alternative Model for Personality Disorders and Clinical Treatment: a Review |url=https://link.springer.com/10.1007/s40501-019-00187-7 |journal=Current Treatment Options in Psychiatry |language=en |volume=6 |issue=4 |pages=284–298 |doi=10.1007/s40501-019-00187-7 |issn=2196-3061}}</ref> Replacing [[ICD-10 classification of personality disorders|the previously used categorical model]], the dimensional [[ICD-11 classification of personality disorders]] classifies personality disorders in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology.<ref name=":72" />
====DSM-5==== {{Further|Classification of personality disorders#DSM-5}}
In Section II, the categorical framework of previous DSM editions has been retained,<ref>{{Cite journal |last1=Strickland |first1=Casey M. |last2=Hopwood |first2=Christopher J. |last3=Bornovalova |first3=Marina A. |last4=Rojas |first4=Elizabeth C. |last5=Krueger |first5=Robert F. |last6=Patrick |first6=Christopher J. |date=April 2019 |title=Categorical and Dimensional Conceptions of Personality Pathology in ''DSM-5'': Toward a Model-Based Synthesis |journal=Journal of Personality Disorders |volume=33 |issue=2 |pages=185–213 |doi=10.1521/pedi_2018_32_339 |pmid=29505383 |issn=0885-579X}}</ref> with criteria remaining the same as in the [[DSM-IV-TR]].<ref>{{Cite journal |last=Trestman |first=Robert L. |date=2014 |title=DSM-5 and personality disorders: where did axis II go? |journal=The Journal of the American Academy of Psychiatry and the Law |volume=42 |issue=2 |pages=141–145 |issn=1943-3662 |pmid=24986340 |quote=The APA Board of Trustees ultimately decided to keep all 10 personality disorders from DSM-IV-TR unchanged (with only minor text updating).}}</ref> This classification contains ten specific personality disorder categories, grouped into three clusters. NPD is located in [[Cluster B]], the disorders belonging to which often appear dramatic, emotional, or erratic.<ref name="DSM5" />
In this system, narcissistic personality disorder is characterized as "a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy [...]", with the requirement that the person who receives the diagnosis meets at least five of nine specified criteria.<ref name=":19">{{Cite journal |last=Skodol |first=Andrew E. |author-link=Andrew E. Skodol |last2=Bender |first2=Donna S. |last3=Morey |first3=Leslie C. |author-link3=Leslie C. Morey |date=2014 |title=Narcissistic personality disorder in DSM-5. |url=https://doi.apa.org/doi/10.1037/per0000023 |journal=Personality Disorders: Theory, Research, and Treatment |language=en |volume=5 |issue=4 |pages=422–427 |doi=10.1037/per0000023 |issn=1949-2723}}</ref><ref name="DSM5" /> This characterization of NPD has been found to predominantly represent overt and grandiose manifestations, whereas the covert presentation and "inevitably coexist[ing]" vulnerable manifestations of narcissism are unrepresented.<ref name=":19" /> In a 2018 [[latent structure analysis]], results suggested that the DSM-5 NPD criteria fail to distinguish some aspects of narcissism relevant to diagnosis of NPD and subclinical narcissism.<ref>{{cite journal |vauthors=Aslinger EN, Manuck SB, Pilkonis PA, Simms LJ, Wright AG |date=July 2018 |title=Narcissist or narcissistic? Evaluation of the latent structure of narcissistic personality disorder |journal=Journal of Abnormal Psychology |volume=127 |issue=5 |pages=496–502 |doi=10.31234/osf.io/tv7r9 |pmc=6051431 |pmid=30010367}}</ref>
==== AMPD ==== {{Further|Alternative DSM-5 model for personality disorders}} Having initially been developed as a replacement for the categorical model, the AMPD is located in [[DSM-5#Section III: Emerging measures and models|Section III]] of both the DSM-5 and [[DSM-5-TR]] due to the replacement having been rejected.<ref>{{Cite journal |last1=Sharp |first1=Carla |last2=Clark |first2=Lee Anna |last3=Balzen |first3=Kennedy M. |last4=Widiger |first4=Tom |last5=Stepp |first5=Stephanie |last6=Zimmerman |first6=Mark |last7=Krueger |first7=Robert F. |date=2025 |title=The validity, reliability and clinical utility of the Alternative DSM -5 Model for Personality Disorders ( AMPD ) according to DSM -5 revision criteria |journal=World Psychiatry |language=en |volume=24 |issue=3 |pages=319–340 |doi=10.1002/wps.21339 |issn=1723-8617 |pmc=12434376 |pmid=40948060}}</ref> In this model, personality disorders are defined through combinations of impairment in personality functioning (criterion A) as well as the presence of pathological personality traits (criterion B);<ref name=":20">{{Cite journal |last1=Zimmermann |first1=Johannes |last2=Kerber |first2=André |last3=Rek |first3=Katharina |last4=Hopwood |first4=Christopher J. |last5=Krueger |first5=Robert F. |date=2019-08-13 |title=A Brief but Comprehensive Review of Research on the Alternative DSM-5 Model for Personality Disorders |journal=Current Psychiatry Reports |language=en |volume=21 |issue=9 |page=92 |doi=10.1007/s11920-019-1079-z |pmid=31410586 |issn=1535-1645}}</ref> further requirements beyond traits and severity, for example relating to [[differential diagnosis]], are embodied in criteria C–G.<ref name=":9" /><ref name=":20" /> Defined through predefined combinations of the A and B criteria, there are six specific personality disorders included in the AMPD.<ref name=":20" /> Of these, NPD is characterized as follows: "Typical features of Narcissistic Personality Disorder are variable and vulnerable self-esteem, with attempts at regulation through attention- and approval-seeking, and either overt or covert grandiosity".<ref name=":19" /><ref name=":10" /> Thus, this characterization "explicitly acknowledges both inflated (grandiose) and deflated (vulnerable) presentations, as well as the possibility of vacillations between the two, although Section II perpetuates the inflated-only presentation".<ref name=":19" />
Criterion A requires that impairment in personality functioning is at least moderate for diagnosis of a personality disorder. The criteria for NPD require that at least two elements of personality functioning, these being: identity, self-direction, empathy and intimacy, must be impaired in a manner characteristic of NPD. In the case of identity, this involves a fragile or exaggerated self-image that depends on others' approval, leading to unstable self-esteem. Impairment in self-direction manifests in personal goals often being shaped by a need for recognition, with standards that are either unrealistically high or based on entitlement. Impairment in empathy involves lacking recognition of what other people feel and need, while their reactions may be a subject of attention in case these are perceived as relevant to the person with NPD. Characteristic impairment in intimacy is manifested in superficial relationships serving to provide self-enhancement rather than mutual connection, with the person with NPD seeking personal gain and lacking interest in what the other experiences.<ref name=":19" /><ref name=":10">{{Cite book |title=Diagnostic and statistical manual of mental disorders: DSM-5 |date=2013 |publisher=American Psychiatric Association |isbn=978-0-89042-554-1 |editor-last=American Psychiatric Association |edition=5th |location=Washington, D.C |pages=767–768 |editor-last2=American Psychiatric Association}}</ref>
Criterion B lists the following pathological traits, both of which are required: grandiosity and attention-seeking. In contrast with the Section II NPD, the feelings of entitlement in grandiosity are recognized in the AMPD to manifest both in overt and covert forms. Specifiers allow for additional traits to be specified; there are suggested additional traits of antagonism for "malignant", and traits of [[negative affectivity]] for "vulnerable" manifestations of NPD.<ref name=":19" /><ref name=":10" /> Further requirements beyond traits and severity, for example relating to [[differential diagnosis]], are embodied in criteria C–G.<ref name=":9" />
====ICD-11==== {{Further|ICD-11 classification of personality disorders}}
The [[World Health Organization]]'s [[ICD-11]] has replaced the categorical classification of personality disorders in the [[ICD-10]] with a [[Dimensional models of personality disorders|dimensional model]] containing a unified ''personality disorder'' ({{ICD11|6D10}}) with severity specifiers, along with specifiers for ''[[prominent personality traits or patterns]]'' ({{ICD11|6D11}}).<ref name="Bach_2018">{{cite journal |vauthors=Bach B, First MB |date=October 2018 |title=Application of the ICD-11 classification of personality disorders |journal=BMC Psychiatry |volume=18 |issue=1 |doi=10.1186/s12888-018-1908-3 |pmc=6206910 |pmid=30373564 |doi-access=free |article-number=351}}</ref> Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder,<ref>{{Cite journal |last=Swales |first=Michaela A. |date=2022-12-15 |title=Personality Disorder Diagnoses in ICD-11: Transforming Conceptualisations and Practice |url=https://cpe.psychopen.eu/index.php/cpe/article/view/9635 |journal=Clinical Psychology in Europe |language=en |volume=4 |issue=Spec Issue |article-number=e9635 |doi=10.32872/cpe.9635 |pmid=36760321 |issn=2625-3410 |pmc=9881116}}</ref> while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.<ref name=":13">{{Cite journal |last1=Bach |first1=Bo |last2=Kramer |first2=Ueli |last3=Doering |first3=Stephan |last4=di Giacomo |first4=Ester |last5=Hutsebaut |first5=Joost |last6=Kaera |first6=Andres |last7=De Panfilis |first7=Chiara |last8=Schmahl |first8=Christian |last9=Swales |first9=Michaela |last10=Taubner |first10=Svenja |last11=Renneberg |first11=Babette |date=2022-04-01 |title=The ICD-11 classification of personality disorders: a European perspective on challenges and opportunities |journal=Borderline Personality Disorder and Emotion Dysregulation |volume=9 |issue=1 |page=12 |doi=10.1186/s40479-022-00182-0 |doi-access=free |pmid=35361271 |issn=2051-6673 |pmc=8973542}}</ref>
Studies have shown that NPD corresponds well to the ICD-11 trait of ''[[Dissociality in personality disorder or personality difficulty|Dissociality]]'' ({{ICD11|6D11.2}})<ref name=":12">{{Cite journal |last1=Simon |first1=Jonatan |last2=Lambrecht |first2=Bastian |last3=Bach |first3=Bo |date=2023-04-06 |title=Cross-walking personality disorder types to ICD-11 trait domains: An overview of current findings |journal=Frontiers in Psychiatry |language=English |volume=14 |article-number=1175425 |doi=10.3389/fpsyt.2023.1175425 |doi-access=free |issn=1664-0640 |pmc=10116048 |pmid=37091704}}</ref><ref name=":13" /> – especially self-centredness<ref name=":13" /> (grandiosity, attention-seeking, entitlement and egocentricity; ''Dissociality'' also includes lack of empathy<ref name="Bach_2018" />), which "can be manifested as an expectation of others' admiration, attention-seeking behaviours to ensure being the center of others' focus, and anger or denigration of others when the admiration and attention that the individual expects are not granted."<ref name=":13" /> Vulnerable features are associated with [[Negative affectivity in personality disorder or personality difficulty|''Negative Affectivity'']] ({{ICD11|6D11.0}}),<ref name=":12" /> which "may characterize some individuals with vulnerable narcissism who are ruminating over perceived slights or insults from others, are overreactive to criticism, and have a low frustration tolerance that easily makes them become overtly or covertly upset over even minor issues."<ref name=":13" /> [[File:12888 2018 1908 Fig5.png|thumb|442x442px|An ICD-11 case profile of a presentation aligning with ''[[Anankastic personality disorder|anankastic]]'' and ''other specific (narcissistic)'' PD diagnoses in the ICD-10 could look like this.<ref name="Bach_2018" />]] NPD also shows secondary links to ''[[Anankastia in personality disorder or personality difficulty|Anankastia]]'' ({{ICD11|6D11.4}}) and [[Disinhibition in personality disorder or personality difficulty|''Disinhibition'']] ({{ICD11|6D11.3}}).<ref name=":12" /> The connection to ''Anankastia'' may reflect perfectionistic traits that support grandiosity and competitiveness,<ref name=":12" /><ref name=":13" /> while the link to ''Disinhibition'' may involve impulsivity, overconfidence, and difficulty with long-term planning.<ref name=":12" /> The complex and variable trait profile across ICD-11 domains reflects the diverse presentations of narcissism.<ref name=":12" /> The involvement of multiple domains supports the traditional view that narcissistic pathology entails moderate to severe impairments in personality functioning.<ref name=":12" />
===Differential diagnosis and comorbidity=== NPD may be comorbid or differentiated with the occurrence of other mental disorders.<ref name="DSM5" /> In regards to personality disorders, NPD mainly overlaps with Cluster B personality disorders, which are characterized by impulsivity, an inability to regulate emotions, and a difficulty maintaining social relationships; these are [[borderline personality disorder]] (BPD), [[antisocial personality disorder]] (ASPD), and [[histrionic personality disorder]] (HPD).<ref name=":6">{{Cite web |title=APA Dictionary of Psychology |url=https://dictionary.apa.org/personality-disorder |access-date=2024-12-08 |website=dictionary.apa.org |language=en}}</ref> Another PD comorbidity is [[paranoid personality disorder]].<ref name="DSM5" />
Borderline PD is characterized as having an instability in emotions, relationships, and self image.<ref name=":14">{{Cite journal |last1=Douk |first1=K |last2=Belabess |first2=I |last3=Hanine |first3=I |date=2023 |title=Comorbidity borderline-narcissistic personality disorder |journal=European Psychiatry |volume=66 |issue=Suppl 1 |pages=S364 |doi= 10.1192/j.eurpsy.2023.790 |doi-broken-date=22 April 2026|pmc=10434708}}</ref> The presence of BPD is also highly associated with traits such as grandiosity, lack of empathy, and praise-seeking behaviors which are characteristic of NPD. Research has shown that BPD has high comorbidity rates with NPD.<ref name=":15">{{Cite journal |last1=Bornstein |first1=Robert F. |last2=Gold |first2=Stephanie H. |date=2008-06-01 |title=Comorbidity of Personality Disorders and Somatization Disorder: A Meta-analytic Review |url=https://link.springer.com/article/10.1007/s10862-007-9052-2 |journal=Journal of Psychopathology and Behavioral Assessment |language=en |volume=30 |issue=2 |pages=154–161 |doi=10.1007/s10862-007-9052-2 |issn=1573-3505 |url-access=subscription}}</ref> Antisocial Personality Disorder is similarly characterized by impulsivity and a lack of empathy, but also by a disregard for the rights of others and a tendency to manipulate others.<ref name=":16">{{Cite web |title=Antisocial Personality Disorder: Often Overlooked and Untreated |url=https://www.psychiatry.org/news-room/apa-blogs/antisocial-personality-disorder-often-overlooked#:~:text=People%20with%20antisocial%20personality%20disorder,show%20no%20remorse%20or%20guilt. |access-date=2024-12-08 |website=www.psychiatry.org |language=en}}</ref> Additionally, both antisociality and narcissism are heavily correlated with [[psychopathy]], further suggesting an overlap between the two.<ref name=":17">{{Cite journal |last1=Sylvers |first1=Patrick |last2=Brubaker |first2=Nicholas |last3=Alden |first3=S. Amanda |last4=Brennan |first4=Patricia A. |last5=Lilienfeld |first5=Scott O. |date=2008-10-01 |title=Differential endophenotypic markers of narcissistic and antisocial personality features: A psychophysiological investigation |journal=Journal of Research in Personality |volume=42 |issue=5 |pages=1260–1270 |doi=10.1016/j.jrp.2008.03.010 }}</ref>
NPD should also be differentiated from [[mania]] and [[hypomania]] as these cases can also present with grandiosity, but present with different levels of functional impairment.<ref name="DSM5" /> It is common for children and adolescents to display personality traits that resemble NPD, but such occurrences are usually transient, and register below the clinical criteria for a formal diagnosis of NPD.<ref name="mayo1">{{cite web |date=18 November 2017 |title=Narcissistic personality disorder – Symptoms & causes |url=https://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/symptoms-causes/syc-20366662 |access-date=28 June 2018 |website=[[Mayo Clinic]] |publisher=Mayo Foundation for Medical Education and Research |location=Phoenix, Arizona}}</ref>
Normalcy must also be ruled out; as is stated in the DSM-5: "Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting, and cause significant functional impairment or subjective distress, do they constitute narcissistic personality disorder."<ref name="DSM5" /> The person's manifested personality traits must substantially differ from [[social norm]]s.<ref name="DSM5" />
==Subtypes== Although the DSM-5 diagnostic criteria for NPD has been viewed as homogeneous, there are a variety of subtypes used for classification of NPD.<ref name="Caligor_2015" /><ref name="Levy_20122">{{cite journal | vauthors = Levy KN | title = Subtypes, dimensions, levels, and mental states in narcissism and narcissistic personality disorder | journal = Journal of Clinical Psychology | volume = 68 | issue = 8 | pages = 886–897 | date = August 2012 | pmid = 22740389 | doi = 10.1002/jclp.21893 }}</ref><ref name="Sedikides_20212">{{cite journal | vauthors = Sedikides C | title = In Search of Narcissus | journal = Trends in Cognitive Sciences | volume = 25 | issue = 1 | pages = 67–80 | date = January 2021 | pmid = 33229145 | doi = 10.1016/j.tics.2020.10.010 | s2cid = 227063824 | url = https://eprints.soton.ac.uk/445148/1/In_search_of_narcissus.docx }}</ref> There is poor consensus on how many subtypes exist, but there is broad acceptance that there are at least two: grandiose or overt narcissism, and vulnerable or covert narcissism.<ref name="Yakeley_2018" /><ref name="Levy_20122" /> However, none of the subtypes of NPD are recognized in the DSM-5 or in the ICD-11.
===Empirically verified subtypes=== Some research has indicated the existence of three subtypes of NPD,<ref name="Russ_200822">{{cite journal | vauthors = Russ E, Shedler J, Bradley R, Westen D | title = Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes | journal = The American Journal of Psychiatry | volume = 165 | issue = 11 | pages = 1473–1481 | date = November 2008 | pmid = 18708489 | doi = 10.1176/appi.ajp.2008.07030376 }}</ref> which can be distinguished by symptom criteria, comorbidity and other clinical criteria. These are as follows:
'''Grandiose/overt''': the group exhibits [[grandiosity]], entitlement, interpersonal exploitativeness and manipulation, pursuit of power and control, lack of empathy and remorse, and marked irritability and hostility.<ref name="Hoffman">{{cite journal | vauthors = Miller JD, Hoffman BJ, Gaughan ET, Gentile B, Maples J, Keith Campbell W | title = Grandiose and vulnerable narcissism: a nomological network analysis | journal = Journal of Personality | volume = 79 | issue = 5 | pages = 1013–1042 | date = October 2011 | pmid = 21204843 | doi = 10.1111/j.1467-6494.2010.00711.x | publisher = [[Wiley (publisher)|Wiley]] }}</ref> This group was noted for high levels of comorbid [[Antisocial personality disorder|antisocial]] and [[Paranoid personality disorder|paranoid]] personality disorders, [[substance abuse]], [[Externalizing disorder|externalizing]], unemployment and greater likelihood of violence.<ref name="Russ_200822" /><ref name="Tanzilli_202022"/> Of note, Russ et al. observed that this group "do not appear to suffer from underlying feelings of inadequacy or to be prone to negative affect states other than anger", an observation corroborated by recent research which found this variant to show strong inverse associations with depressive, anxious-avoidant, and dependant/victimised features.<ref name="Tanzilli_202022" />
'''Vulnerable/covert''': this variant is defined by feelings of shame, envy, resentment, and inferiority (which is occasionally "masked" by arrogance), entitlement, a belief that one is misunderstood or unappreciated, and excessive reactivity to slights or criticism. This variant is associated with elevated levels of neuroticism, psychological distress, depression, and anxiety. Recent research suggests that vulnerable narcissism is mostly the product of dysfunctional levels of [[neuroticism]].<ref>{{Cite journal |last1=Miller |first1=Joshua D. |last2=Lynam |first2=Donald R. |last3=Vize |first3=Colin |last4=Crowe |first4=Michael |last5=Sleep |first5=Chelsea |last6=Maples-Keller |first6=Jessica L. |last7=Few |first7=Lauren R. |last8=Campbell |first8=W. Keith |date=April 2018 |title=Vulnerable Narcissism Is (Mostly) a Disorder of Neuroticism |url=https://onlinelibrary.wiley.com/doi/10.1111/jopy.12303 |journal=Journal of Personality |language=en |volume=86 |issue=2 |pages=186–199 |doi=10.1111/jopy.12303 |pmid=28170100 |issn=0022-3506|url-access=subscription }}</ref> Vulnerable narcissism is sometimes comorbid with diagnoses of [[Avoidant personality disorder|avoidant]], [[Borderline personality disorder|borderline]] and [[Dependent personality disorder|dependent]] personality disorders.<ref name="Russ_200822" /><ref name="Tanzilli_202022" />
'''High-functioning/exhibitionistic''': A third subtype for classifying people with NPD, initially theorized by psychiatrist [[Glen Gabbard]], is termed high functioning or exhibitionistic.<ref name="Gabbard_2022" /><ref name="Russ_200822"/> This variant has been described as "high functioning narcissists [who] were grandiose, competitive, attention-seeking, and sexually provocative; they tended to show adaptive functioning and utilize their narcissistic traits to succeed."<ref name="Levy_20122"/> This group has been found to have relatively few psychological issues and high rates of [[Obsessive–compulsive personality disorder|obsessive-compulsive personality disorder]], with excessive perfectionism posited as a potential cause for their impairment.<ref name="Russ_200822" />
===Others=== '''[[Codependency|Oblivious]]/[[Grandiosity|hypervigilant]]:''' Glen Gabbard described two subtypes of NPD in 1989, later referred to as equivalent to, the grandiose and vulnerable subtypes.<ref>{{Cite journal | vauthors = Gabbard GO |date=1989 |title=Two subtypes of narcissistic personality disorder |journal=Bulletin of the Menninger Clinic |volume=53 |issue=6 |pages=527–532|pmid=2819295 }}</ref><ref>{{Cite journal | vauthors = Gabbard GO |date=March 2009 |title=Transference and Countertransference: Developments in the Treatment of Narcissistic Personality Disorder |journal=[[Psychiatric Annals]] |publisher=SLACK Incorporated|location=Thorofare, New Jersey|volume=39 |issue=3 |pages=129–136 |doi=10.3928/00485713-20090301-03 |issn=0048-5713}}</ref><ref name="Gabbard_2022">{{cite journal | vauthors = Gabbard GO | title = Narcissism and suicide risk | journal = Annals of General Psychiatry | volume = 21 | issue = 1 | article-number = 3 | date = January 2022 | pmid = 35065658 | doi = 10.1186/s12991-022-00380-8 | publisher = BioMed Central Ltd. | pmc = 8783517 | s2cid = 246083162 | doi-access = free }}</ref> The first was the "oblivious" subtype of narcissist, equivalent to the grandiose subtype. This group was described as being grandiose, arrogant and thick-skinned, while also exhibiting personality traits of helplessness and emotional emptiness, low self-esteem and shame. These were observed in people with NPD to be expressed as socially avoidant behavior in situations where self-presentation is difficult or impossible, leading to withdrawal from situations where social approval is not given.
The second subtype Gabbard described was termed "hypervigilant", equivalent to the vulnerable subtype. People with this subtype of NPD were described as having easily hurt feelings, an oversensitive [[temperament]], and persistent feelings of shame.
'''Communal narcissism:''' A fourth type is the communal narcissist. Communal narcissism is a form of narcissism that occurs in group settings. It is characterized by an inflated sense of importance and a need for admiration from others. In relation to the grandiose narcissist, a communal narcissist is arrogant and self-motivating, and shares the sense of entitlement and grandiosity. However, the communal narcissist seeks power and admiration in the communal realm. They see themselves as altruistic, saintly, caring, helpful, and warm.<ref name="pmid22889074">{{cite journal | vauthors = Gebauer JE, Sedikides C, Verplanken B, Maio GR | title = Communal narcissism | journal = Journal of Personality and Social Psychology | volume = 103 | issue = 5 | pages = 854–878 | date = November 2012 | pmid = 22889074 | doi = 10.1037/a0029629 }}</ref><ref>{{cite web |date=6 March 2021 |title=Know the Kind of Narcissist You're Dealing With and Symptoms |url=https://www.psychologytoday.com/us/blog/toxic-relationships/202103/know-the-kind-narcissist-youre-dealing-and-symptoms |publisher=PsychologyToday.com |vauthors=Lancer D}}</ref> Individuals who display communal narcissism often seek out positions of power and influence within their groups.
====Millon's subtypes==== In the study ''Disorders of Personality: DSM-IV-TM and Beyond'' (1996), [[Theodore Millon]] suggested five subtypes of NPD, although he did not identify specific treatments per subtype.<ref name="Millon1">{{cite book |author-link=Theodore Millon |title=Disorders of Personality: DSM-IV and Beyond |vauthors=Millon T, Davis RD |publisher=[[Wiley (publisher)|John Wiley & Sons, Inc.]] |year=1996 |isbn=978-0-471-01186-6 |location=New York City |page=226}}</ref> {| class="wikitable" |+ !Subtype !Traits |- |'''''Unprincipled narcissist''''' |Deficient conscience; unscrupulous, amoral, disloyal, fraudulent, deceptive, arrogant, exploitive; a con artist and charlatan; dominating, contemptuous, vindictive. |- |'''''Amorous narcissist''''' |Sexually seductive, enticing, beguiling, tantalizing; glib and clever; disinclined to real intimacy; indulges hedonistic desires; bewitches and inveigles others; pathological lying and swindling. Tends to have many affairs.{{citation needed|date=December 2025}} |- |'''''[[Compensation (psychology)|Compensatory]] narcissist''''' |Seeks to counteract or cancel out deep feelings of [[inferiority complex|inferiority]] and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, noteworthy; self-worth results from self-enhancement. |- |'''''[[Elitism|Elitist]] narcissist''''' |Feels privileged and empowered by virtue of special childhood status and pseudo-achievements; entitled façade bears little relation to reality; seeks favored and good life; is upwardly mobile; cultivates special status and advantages by association. |- |'''''Normal narcissist''''' |Least severe and most interpersonally concerned and empathetic, still entitled and deficient in reciprocity; bold in environments, self-confident, competitive, seeks high targets, feels unique; talent in leadership positions; expecting recognition from others. |}
====Masterson's subtypes (exhibitionist and closet)==== In 1993, [[James F. Masterson]] proposed two subtypes for pathological narcissism, exhibitionist and closet.<ref name="masterson">{{cite book| vauthors = Masterson JF |title=The Emerging Self: A Developmental Self & Object Relations Approach to the Treatment of the Closet Narcissistic Disorder of the Self|publisher=[[Psychology Press]]|location=Hove, Sussex, England|date=1993|isbn=978-1-315-82578-6|page=4}}</ref> Both fail to adequately develop an age- and phase- appropriate self because of defects in the quality of psychological nurturing provided, usually by the mother. A person with exhibitionist narcissism is similar to NPD described in the [[DSM-IV]] and differs from closet narcissism in several ways. A person with closet narcissism is more likely to be described as having a deflated, inadequate self-perception and greater awareness of emptiness within. A person with exhibitionist narcissism would be described as having an inflated, grandiose self-perception with little or no conscious awareness of feelings of emptiness. Such a person would assume that their condition was normal and that others were just like them. A person with closet narcissism is described to seek constant approval from others and appears similar to those with [[borderline personality disorder]] in the need to please others. A person with exhibitionist narcissism seeks perfect admiration all the time from others.<ref name=asrotr/>
====Malignant narcissism==== {{Main|Malignant narcissism}}
Malignant narcissism, a term first coined in [[Erich Fromm]]'s 1964 book ''The Heart of Man: Its Genius for Good and Evil'',<ref name="fromm2">{{cite book| vauthors = Fromm E |author-link=Erich Fromm|title=The Heart of Man: Its Genius for Good and Evil|publisher=[[Harper & Row]]|location=San Francisco|date=1964 |page=92}}</ref> is a [[syndrome]] consisting of a combination of NPD, [[antisocial personality disorder]], and [[paranoia|paranoid]] traits. A person with malignant narcissism was described as deriving higher levels of psychological [[gratification]] from accomplishments over time, suspected to worsen the disorder. Because a person with malignant narcissism becomes more involved in psychological gratification, it was suspected to be a risk factor for developing [[antisocial personality disorder|antisocial]], [[paranoid personality disorder|paranoid]], and [[schizoid]] personality disorders. The term ''[[malignant]]'' is added to the term ''narcissist'' to indicate that individuals with this disorder have a severe form of narcissistic disorder that is characterized also by features of paranoia, [[psychopathy]] ([[anti-social behavior]]s), aggression, and [[Sadistic personality disorder|sadism]].<ref name="pmid30184541">{{cite journal | vauthors = Lenzenweger MF, Clarkin JF, Caligor E, Cain NM, Kernberg OF | title = Malignant Narcissism in Relation to Clinical Change in Borderline Personality Disorder: An Exploratory Study | journal = Psychopathology | volume = 51 | issue = 5 | pages = 318–325 | date = 2018 | pmid = 30184541 | doi = 10.1159/000492228 | s2cid = 52160230 }}</ref>
====Historical demarcation of grandiose and vulnerable types==== Over the years, many clinicians and theorists have described two variants of NPD akin to the grandiose and vulnerable expressions of trait narcissism. Some examples include:<ref>{{cite book |title=The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments |vauthors=Pincus AL, Roche MJ |date=2011 |publisher=John Wiley & Sons, Inc. |isbn=978-1-118-09310-8 |veditors=Campbell WK, Miller JD |pages=31–40 |chapter=Narcissistic Grandiosity and Narcissistic Vulnerability |doi=10.1002/9781118093108.ch4}}</ref> {| class="wikitable" |+ ! !Grandiose Phenotype !Vulnerable Types |- |Kohut & Wolf (1978) |Mirror-hungry |Ideal-hungry |- |Broucek (1982) |Egotistical |Dissociative |- |Rosenfeld (1987) |Thick-skinned |Thin-skinned |- |Gabbard (1989, 1998, 2009) |Oblivious |Hypervigilant |- |Gersten (1991) |Overly grandiose |Overly vulnerable |- |Wink (1992) |Willful |Hypersensitive |- |Masterson (1993) |Exhibitionist |Closet |- |Fiscalini (1993) |Special child |Shamed child |- |Cooper and Maxwell (1995) |Empowered |Disempowered |}
==Assessment and screening== ===Narcissistic Personality Inventory=== {{Main|Narcissistic Personality Inventory}}
Risk factors for NPD and grandiose/overt and vulnerable/covert subtypes are measured using the [[Narcissistic Personality Inventory|narcissistic personality inventory]], an assessment tool originally developed in 1979, which has undergone multiple iterations with new versions in 1984, 2006 and 2014. It captures principally grandiose narcissism, but also seems to capture elements of vulnerability. A popular three-factor model has it that grandiose narcissism is assessed via the Leadership/Authority and Grandiose/Exhibitionism facets, while a combination of grandiose and vulnerable traits are indexed by the Entitlement/Exploitativeness facet.<ref name="Miller_20162">{{cite journal | vauthors = Miller JD, Lynam DR, Campbell WK | title = Measures of Narcissism and Their Relations to DSM-5 Pathological Traits: A Critical Reappraisal | journal = Assessment | volume = 23 | issue = 1 | pages = 3–9 | date = February 2016 | pmid = 24550548 | doi = 10.1177/1073191114522909 | s2cid = 24303584 }}</ref>
===Pathological Narcissism Inventory=== The Pathological Narcissism Inventory (PNI) was designed to measure fluctuations in grandiose and vulnerable narcissistic states, similar to what is ostensibly observed by some clinicians (though empirical demonstration of this phenomenon is lacking). While having both "grandiosity" and vulnerability scales, empirically both seem to primarily capture vulnerable narcissism.<ref name="Miller_20162"/><ref name="pmid26463683">{{cite journal | vauthors = Miller JD, Lynam DR, Campbell WK | title = Rejoinder: A Construct Validity Approach to the Assessment of Narcissism | journal = Assessment | volume = 23 | issue = 1 | pages = 18–22 | date = February 2016 | pmid = 26463683 | doi = 10.1177/1073191115608943 | s2cid = 220416652 }}</ref>
The PNI scales show significant associations with [[parasuicidal]] behavior, suicide attempts, homicidal ideation, and several aspects of psychotherapy utilization.<ref name="Pincus_2009">{{cite journal | vauthors = Pincus AL, Ansell EB, Pimentel CA, Cain NM, Wright AG, Levy KN | title = Initial construction and validation of the Pathological Narcissism Inventory | journal = Psychological Assessment | volume = 21 | issue = 3 | pages = 365–379 | date = September 2009 | pmid = 19719348 | doi = 10.1037/a0016530 | publisher = [[American Psychological Association]] }}</ref>
===Five-Factor Narcissism Inventory=== In 2013, the Five-Factor Narcissism Inventory (FFNI) was defined as a comprehensive assay of grandiose and vulnerable expressions of trait narcissism. The scale measures 11 traits of grandiose narcissism and 4 traits of vulnerable narcissism, both of which correlate with clinical ratings of NPD (with grandiose features of arrogance, grandiose fantasies, manipulativeness, entitlement and exploitativeness showing stronger relations).<ref name="pmid23647044">{{cite journal | vauthors = Miller JD, Few LR, Wilson L, Gentile B, Widiger TA, Mackillop J, Keith Campbell W | title = The Five-Factor Narcissism Inventory (FFNI): a test of the convergent, discriminant, and incremental validity of FFNI scores in clinical and community samples | journal = Psychological Assessment | volume = 25 | issue = 3 | pages = 748–758 | date = September 2013 | pmid = 23647044 | doi = 10.1037/a0032536 }}</ref> Later analysis revealed that the FFNI actually measures three factors:<ref name="Kaufman_2020">{{cite journal | vauthors = Kaufman SB, Weiss B, Miller JD, Campbell WK | title = Clinical Correlates of Vulnerable and Grandiose Narcissism: A Personality Perspective | journal = Journal of Personality Disorders | volume = 34 | issue = 1 | pages = 107–130 | date = February 2020 | pmid = 30179576 | doi = 10.1521/pedi_2018_32_384 | s2cid = 52154467 | doi-access = free }}</ref>
# '''Agentic Extraversion''': an exaggerated sense of self-importance, grandiose fantasies, striving for greatness and acclaim, social dominance and authoritativeness, and exhibitionistic, charming interpersonal conduct. # '''Self-Centred Antagonism''': disdain for others, psychological entitlement, interpersonally exploitative and manipulative behaviour, lack of empathy, anger in response to criticism or rebuke, suspiciousness, and thrill-seeking. # '''Narcissistic Neuroticism''': shame-proneness, oversensitivity and negative emotionality to criticism and rebuke, and excessive need for admiration to maintain self-esteem.
Grandiose narcissism is a combination of agency and antagonism, and vulnerability is a combination of antagonism and neuroticism. The three factors show differential associations with clinically important variables. Agentic traits are associated with high self-esteem, positive view of others and the future, autonomous and authentic living, commitment to personal growth, sense of purpose in life and life satisfaction. Neurotic traits show precisely the opposite correlation with all of these variables, while antagonistic traits show more complex associations; they are associated with negative view of others (but not necessarily of the self), a sense of alienation from their 'true self', disinterest in personal growth, negative relationships with others, and all forms of aggression.<ref name="Kaufman_2020" /><ref name="Du_2022">{{cite journal | vauthors = Du TV, Miller JD, Lynam DR | title = The relation between narcissism and aggression: A meta-analysis | journal = Journal of Personality | volume = 90 | issue = 4 | pages = 574–594 | date = August 2022 | pmid = 34689345 | doi = 10.1111/jopy.12684 | s2cid = 239767063 }}</ref>
===Millon Clinical Multiaxial Inventory=== {{Main|Millon Clinical Multiaxial Inventory}}
The Millon Clinical Multiaxial Inventory (MCMI) is another diagnostic test developed by [[Theodore Millon]]. The MCMI includes a scale for narcissism. The NPI and MCMI have been found to be well correlated.<ref>{{cite journal | vauthors = Auerbach JS | title = Validation of two scales for narcissistic personality disorder | journal = Journal of Personality Assessment | volume = 48 | issue = 6 | pages = 649–653 | date = December 1984 | pmid = 6520692 | doi = 10.1207/s15327752jpa4806_13 | publisher = [[Taylor & Francis]] }}</ref> Whereas the MCMI measures narcissistic personality disorder (NPD), the NPI measures narcissism as it occurs in the general population; the MCMI is a [[Screening (medicine)|screening tool]]. In other words, the NPI measures "normal" narcissism; i.e., most people who score very high on the NPI do not have NPD. Indeed, the NPI does not capture any sort of narcissism taxon as would be expected if it measured NPD.<ref name="Foster_2007">{{cite journal |vauthors=Foster JD, Campbell WK |date=October 2007 |title=Are there such things as 'Narcissists'? A taxometric analysis of the Narcissistic Personality Inventory |journal=[[Personality and Individual Differences]] |location=Amsterdam, Netherlands |publisher=[[Elsevier]] |volume=43 |issue=6 |doi=10.1016/j.paid.2007.04.003}}</ref>
A 2020 study found that females scored significantly higher on vulnerable narcissism than males, but no gender differences were found for grandiose narcissism.<ref>{{Cite journal |vauthors=Green A, MacLean R, Charles K |date=December 1, 2020 |title=Recollections of parenting styles in the development of narcissism: The role of gender |url=https://napier-surface.worktribe.com/2676428/1/Recollections%20Of%20Parenting%20Styles%20In%20The%20Development%20Of%20Narcissism%3A%20The%20Role%20Of%20Gender%20%28accepted%20version%29 |journal=[[Personality and Individual Differences]] |language=en |location=Amsterdam, Netherlands |publisher=[[Elsevier]] |volume=167 |article-number=110246 |doi=10.1016/j.paid.2020.110246 |issn=0191-8869 |s2cid=224958195|doi-access=free }}</ref>
==Management== Treatment for NPD is primarily [[Psychotherapy|psychotherapeutic]]; there is no clear evidence that [[Psychopharmacology|psychopharmacological]] treatment is effective for NPD, although it can prove useful for treating comorbid disorders.<ref name="Yakeley_2018"/><ref name="mayo2">{{cite web |date=18 November 2017 |title=Narcissistic personality disorder – Diagnosis and treatment |url=https://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/diagnosis-treatment/drc-20366690 |access-date=28 June 2018 |website=mayoclinic.org}}</ref> Psychotherapeutic treatment falls into two general categories: [[Psychoanalysis|psychoanalytic]]/[[Psychodynamic psychotherapy|psychodynamic]] and cognitive behavioral. Psychoanalytic therapies include [[schema therapy]], [[transference focused psychotherapy]], [[mentalization-based treatment]] and [[Metacognitive therapy|metacognitive psychotherapy]]. Cognitive behavioral therapies include [[cognitive behavioral therapy]] and [[Dialectical behavior therapy|dialectal behavior therapy]]. Formats also include [[group therapy]] and [[couples therapy]].<ref name=":Ronningstam_2016" /> The specific choice of treatment varies based on individual presentations.<ref>{{cite journal | vauthors = Kramer U, Berthoud L, Keller S, Caspar F |date=June 2014 |title=Motive-Oriented Psychotherapeutic Relationship Facing a Patient Presenting with Narcissistic Personality Disorder: A Case Study |journal=Journal of Contemporary Psychotherapy |volume=44 |issue=2 |pages=71–82 |doi=10.1007/s10879-013-9249-5 |s2cid=9514109 |url=https://boris.unibe.ch/65606/ }}</ref>
Management of narcissistic personality disorder has not been well studied, however many treatments tailored to NPD exist.<ref name="King_2020" /><ref name="Caligor_2015" /> Therapy is complicated by the lack of treatment-seeking behavior in people with NPD, despite [[mental distress]]. Additionally, people with narcissistic personality disorders have decreased life satisfaction and lower qualities of life, irrespective of diagnosis.<ref>{{cite journal | vauthors = Soyer RB, Rovenpor JL, Kopelman RE, Mullins LS, Watson PJ | title = Further assessment of the construct validity of four measures of narcissism: replication and extension | journal = The Journal of Psychology | volume = 135 | issue = 3 | pages = 245–258 | date = May 2001 | pmid = 11577967 | doi = 10.1080/00223980109603695 | s2cid = 31486515 }}</ref><ref name="pmid26874362">{{cite journal | vauthors = Morf CC, Schürch E, Küfner A, Siegrist P, Vater A, Back M, Mestel R, Schröder-Abé M | title = Expanding the Nomological Net of the Pathological Narcissism Inventory: German Validation and Extension in a Clinical Inpatient Sample | journal = Assessment | volume = 24 | issue = 4 | pages = 419–443 | date = June 2017 | pmid = 26874362 | doi = 10.1177/1073191115627010 | s2cid = 13765609 }}</ref><ref>{{Cite journal| vauthors = Egan V, Chan S, Shorter GW |date=September 2014|title=The Dark Triad, happiness and subjective well-being |journal=Personality and Individual Differences|language=en|volume=67|pages=17–22|doi=10.1016/j.paid.2014.01.004|s2cid=17277308 |url=https://pureadmin.qub.ac.uk/ws/files/219337558/Wellbeing.pdf }}</ref><ref>{{cite journal | vauthors = Soeteman DI, Verheul R, Busschbach JJ | title = The burden of disease in personality disorders: diagnosis-specific quality of life | journal = Journal of Personality Disorders | volume = 22 | issue = 3 | pages = 259–268 | date = June 2008 | pmid = 18540798 | doi = 10.1521/pedi.2008.22.3.259 | hdl = 1765/62721 | hdl-access = free }}</ref><ref name=naqol/> People with NPD often present with comorbid mental disorders, complicating diagnosis and treatment.<ref name="Caligor_2015">{{cite journal | vauthors = Caligor E, Levy KN, Yeomans FE | title = Narcissistic personality disorder: diagnostic and clinical challenges | journal = The American Journal of Psychiatry | volume = 172 | issue = 5 | pages = 415–422 | date = May 2015 | pmid = 25930131 | doi = 10.1176/appi.ajp.2014.14060723 }}</ref> NPD is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they often express seeking relief from a comorbid mental disorder, including [[major depressive disorder]], a [[substance use disorder]] (drug addiction), or [[bipolar disorder]].<ref name="ronningstam2016" />
==Prognosis== {{As of|2020}}, no treatment guidelines exist for NPD and no empirical studies have been conducted on specific NPD groups to determine efficacy for [[Psychotherapy|psychotherapies]] and [[pharmacology]].<ref name="King_2020" /><ref name="Yakeley_2018"/> Though there is no known single cure for NPD, there are some things one can do to lessen its symptoms. Medications such as antidepressants, which treat depression, are commonly prescribed by healthcare providers; mood stabilizers to reduce mood swings and antipsychotic drugs to reduce the prevalence of psychotic episodes.
The presence of NPD in patients undergoing psychotherapy for the treatment of other mental disorders is associated with slower treatment progress and higher dropout rates.<ref name="Caligor_2015" /> In this therapy, the goals often are examining traits and behaviors that negatively affect life, identifying ways these behaviors cause distress to the person and others, exploring early experiences that contributed to narcissistic defenses, developing new coping mechanisms to replace those defenses, helping the person see themselves and others in more realistic and nuanced ways, rather than wholly good or wholly bad, identifying and practicing more helpful patterns of behavior, developing interpersonal skills, and learning to consider the needs and feelings of others.<ref>{{Cite web |date=17 December 2017 |title=Can Narcissists Change? |url=https://psychcentral.com/disorders/narcissistic-personality-disorder/treatment |website=Psych Central}}</ref>
==Epidemiology== {{As of|2018}}, overall prevalence is estimated to range from 0.8% to 6.2%.<ref>{{cite journal | vauthors = Cailhol L, Pelletier É, Rochette L, Laporte L, David P, Villeneuve É, Paris J, Lesage A | display-authors = 6 | title = Prevalence, Mortality, and Health Care Use among Patients with Cluster B Personality Disorders Clinically Diagnosed in Quebec: A Provincial Cohort Study, 2001-2012 | journal = Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie | volume = 62 | issue = 5 | pages = 336–342 | date = May 2017 | pmid = 28403655 | pmc = 5459230 | doi = 10.1177/0706743717700818 }}</ref><ref>{{cite journal | vauthors = Dhawan N, Kunik ME, Oldham J, Coverdale J | title = Prevalence and treatment of narcissistic personality disorder in the community: a systematic review | journal = Comprehensive Psychiatry | volume = 51 | issue = 4 | pages = 333–339 | date = July–August 2010 | pmid = 20579503 | doi = 10.1016/j.comppsych.2009.09.003 | author4-link = John H. Coverdale }}</ref> In 2008 under the DSM-IV, lifetime prevalence of NPD was estimated to be 6.2%, with 7.7% for men and 4.8% for women,<ref name="auto">{{cite journal | vauthors = Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM, Ruan WJ, Pulay AJ, Saha TD, Pickering RP, Grant BF | display-authors = 6 | title = Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions | journal = The Journal of Clinical Psychiatry | volume = 69 | issue = 7 | pages = 1033–1045 | date = July 2008 | pmid = 18557663 | pmc = 2669224 | doi = 10.4088/jcp.v69n0701 }}</ref> with a 2015 study confirming the gender difference.<ref name="Grijalva">{{cite journal | vauthors = Grijalva E, Newman DA, Tay L, Donnellan MB, Harms PD, Robins RW, Yan T | title = Gender differences in narcissism: a meta-analytic review | journal = Psychological Bulletin | volume = 141 | issue = 2 | pages = 261–310 | date = March 2015 | pmid = 25546498 | doi = 10.1037/a0038231 | url = http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1004&context=pdharms | url-status = live | archive-url = https://web.archive.org/web/20170217233154/http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1004&context=pdharms | archive-date = 17 February 2017 | url-access = subscription }}</ref> In clinical settings, prevalence estimates range from 1% to 15%.<ref name="Mitra_2022" /><ref name="Sed2009">{{cite book | vauthors = Sederer LI | chapter = Chapter 4: Personality Disorders | chapter-url = https://books.google.com/books?id=7_7-5dQIpBQC&pg=PA29 |title=Blueprints Psychiatry |date=2009 |publisher=Wolters Kluwer/Lippincott Williams & Wilkins |isbn=978-0-7817-8253-1 |edition=5th |location=Philadelphia |page=29 |archive-url=https://web.archive.org/web/20170111195341/https://books.google.com/books?id=7_7-5dQIpBQC&pg=PA29 |archive-date=11 January 2017 |url-status=live |via=Google Books |df=dmy-all}}</ref> The same 2008 study presented a significantly higher prevalence of NPD among Black men and women and Hispanic women, younger adults, and separated/divorced/widowed and never married adults.<ref name="auto"/>
The occurrence of narcissistic personality disorder presents a high rate of [[comorbidity]] with other mental disorders.<ref name="Paris_2012" /><ref name="Paris_2014">{{cite journal |vauthors=Paris J |date=April 2014 |title=Modernity and narcissistic personality disorder |journal=Personality Disorders |volume=5 |issue=2 |pages=220–226 |doi=10.1037/a0028580 |pmid=22800179}}</ref> People with a fragile variant of NPD (see Subtypes) are prone to bouts of [[psychological depression]], often to the degree that meets the clinical criteria for a co-occurring [[depressive disorder]].<ref name="medline">{{citation |title=Narcissistic personality disorder |date=8 July 2018 |website=MedlinePlus |url=https://medlineplus.gov/ency/article/000934.htm |publisher=U.S. National Library of Medicine}}</ref> NPD is associated with the occurrence of [[bipolar disorder]] and [[substance use disorders]],<ref name="Caligor_2015" /><ref name="ronningstam2016" /> especially [[cocaine use disorder]].<ref name="DSM5" />
==History== The term "narcissism" comes from the first century (written in the year 8 AD) [[narrative poem]] the ''[[Metamorphoses]]'' by the [[Ancient Rome|Roman]] poet [[Ovid]]. Book III of the ''Metamorphoses'' features a [[myth]] about two main characters, [[Narcissus (mythology)|Narcissus]] and [[Echo (mythology)|Echo]]. Narcissus is a handsome young man who spurns the advances of many potential lovers. When Narcissus rejects Echo, a [[nymph]] cursed to only [[echo]] the sounds that others made, the goddess [[Nemesis]] punishes him by making him fall in love with his own reflection in a pool of water. When Narcissus discovers that the object of his love cannot love him back, he slowly pines away and dies.<ref name="Britannica">{{Cite web |title=Narcissus Greek mythology |url=https://www.britannica.com/topic/Narcissus-Greek-mythology |website=britannica.com |publisher=Britannica |access-date=14 September 2021}}</ref>
The concept of excessive [[selfishness]] has been recognized throughout history. In ancient Greece, the concept was understood as [[hubris]]. It is only since the late 1800s that narcissism has been defined in psychological terms:<ref name="Millon_2004">{{cite book| vauthors = Millon T, Grossman S, Millon C, Meagher S, Ramnath R |publisher = Wiley |isbn = 978-0-471-23734-1 |page = 343|url = http://leipper.org/manuals/zip-fill/Personality%20Disorders%20in%20Modern%20Life%202ND%20ED%20-%20THEODORE%20MILLON.pdf |title= Personality Disorders in Modern Life|year=2004}}</ref>
*'''[[Havelock Ellis]]''' (1898) was the first psychologist to use the term when he linked the myth to the condition in one of his patients.<ref name="Millon_2004" /> *'''[[Sigmund Freud]]''' (1905–1953) used the terms "narcissistic libido" in his ''[[Three Essays on the Theory of Sexuality]]''.<ref name="freud1">{{citation|url=http://www.english.hawaii.edu/criticalink/narc/guide1.html|title=Freud: On Narcissism|year=1998|website = CriticaLink| vauthors = Zuern JD |publisher = University of Hawaii}}.</ref><ref name="Millon_2004" /> *'''[[Ernest Jones]]''' (1913/1951) was the first to construe extreme narcissism as a character flaw. *'''[[Robert Waelder]]''' (1925) published the first case study of narcissism. His patient was a successful scientist with an attitude of superiority, an obsession with fostering self-respect, and a lack of normal feelings of guilt. The patient was aloof and independent from others and had an inability to empathize with others' situations, and was selfish sexually. Waelder's patient was also overly logical and analytical and valued abstract intellectual thought (thinking for thinking's sake) over the practical application of scientific knowledge.
[[Narcissism|Narcissistic personality]] was first described by the psychoanalyst [[Robert Waelder]] in 1925.<ref>{{Cite journal | vauthors = Waelder R |date=1925 |title=The psychoses: Their mechanisms and accessibility to influence |journal=International Journal of Psycho-Analysis |volume=6 |pages=259–281}}</ref> The term ''narcissistic personality disorder'' (NPD) was coined by [[Heinz Kohut]] in 1968.<ref>{{Cite book | vauthors = O'Donohue WT, Fowler KA, Lilienfeld SO |title=Personality disorders: toward the DSM-V |date=2007 |publisher=Sage Publications |isbn=978-1-4129-0422-3 |location=Los Angeles |page=235 |oclc=77716529}}</ref><ref>{{cite journal | vauthors = Kohut H | title = The psychoanalytic treatment of narcissisticppersonality disorders. Outline of a systematic approach | journal = The Psychoanalytic Study of the Child | volume = 23 | pages = 86–113 | date = 1968 | pmid = 5759031 | doi = 10.1080/00797308.1968.11822951 | publisher = [[Taylor & Francis]] | author-link = Heinz Kohut }}</ref> Waelder's initial study has been influential in the way narcissism and the clinical disorder Narcissistic personality disorder are defined today<ref name="Bergmann">{{cite book | vauthors = Bergmann MS |title=''Anatomy of Loving; Man's Quest to Know what Love'' I |date=1987 |publisher=Ballantine Books |isbn=978-0-449-90553-1}}</ref>
===Freudianism and psychoanalysis=== Much of the early history of narcissism and NPD originates from [[psychoanalysis]]. Regarding the adult [[Neuroticism|neurotic]]'s sense of omnipotence, [[Sigmund Freud]] said that "this belief is a frank acknowledgement of a relic of the old megalomania of infancy";<ref>{{Cite book| vauthors = Freud S, Richards A, Strachey J |author-link=Sigmund Freud|title=Case Histories II|date=1990|publisher=[[Penguin Books]]|isbn=978-0-14-013799-6|location=London, England|page=113|language=English|oclc=490712192}}</ref> and concluded that: "we can detect an element of megalomania in most other forms of [[Paranoia|paranoic disorder]]. We are justified in assuming that this megalomania is essentially of an infantile nature, and that, as development proceeds, it is sacrificed to social considerations."<ref>Freud, p. 203.</ref>
''[[Narcissistic injury]]'' and ''narcissistic scar'' are terms used by Freud in the 1920s. ''Narcissistic wound'' and ''narcissistic blow'' are other, almost interchangeable, terms.<ref>{{cite book| vauthors = Akhtar S |author-link=Salman Akhtar|title=Comprehensive Dictionary of Psychoanalysis|publisher=[[Routledge]]|location=Abingdon, England|date=2018|orig-date=2009|isbn=978-1-85575-471-3|page=182}}</ref> When wounded in the ego, either by a real or a perceived criticism, a narcissistic person's displays of anger can be disproportionate to the nature of the criticism suffered;<ref name="mayo1" /> but typically, the actions and responses of the NPD person are deliberate and calculated.<ref name="DSM5" /> Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable.<ref name="DSM5" />
In ''The Psychology of Gambling'' (1957), [[Edmund Bergler]] considered megalomania to be a normal occurrence in the psychology of a child,<ref>{{cite book| vauthors = Bergler E |author-link=Edmund Bergler|title=The Psychology of Gambling| veditors = Halliday J, Fuller P |publisher=[[International Universities Press]]|location=London|date=1974|isbn=978-1-111-91633-6|pages=176, 182}}</ref> a condition later reactivated in adult life, if the individual takes up gambling.<ref>{{cite journal | vauthors = Lindner RM | title = The Psychodynamics of Gambling | journal = The Annals of the American Academy of Political and Social Science | date = May 1950 | volume = 269 | issue = 1 | pages = 93–107 | doi = 10.1177/000271625026900114 | s2cid = 144827078 }}</ref> In ''The Psychoanalytic Theory of Neurosis'' (1946), [[Otto Fenichel]] said that people who, in their later lives, respond with denial to their own narcissistic injury usually undergo a similar [[Regression (psychology)|regression]] to the megalomania of childhood.<ref>{{Cite book| vauthors = Fenichel O |title=Psychoanalytic Theory of Neurosis |date=2016|publisher=[[Taylor & Francis]] |location=Abingdon, England|isbn=978-1-138-14782-9|page=420|language=English|oclc=960836519}}</ref>
====Narcissistic supply==== [[Narcissistic supply]] was a concept introduced by [[Otto Fenichel]] in 1938, to describe a type of [[admiration]], [[Social support|interpersonal support]], or sustenance drawn by an individual from his or her environment and essential to their [[self-esteem]].<ref name="fenichel">{{cite journal |vauthors=Fenichel O |date=1938 |title=The Drive to Amass Wealth |url=http://freudians.org/wp-content/uploads/2014/09/Fenichel-The-Drive-to-Amass-Wealth.pdf |journal=The Psychoanalytic Quarterly |volume=7 |issue=1 |pages=69–95 |doi=10.1080/21674086.1938.11925342 |access-date=16 September 2021 |archive-date=2 November 2019 |archive-url=https://web.archive.org/web/20191102060841/http://freudians.org/wp-content/uploads/2014/09/Fenichel-The-Drive-to-Amass-Wealth.pdf }}</ref> The term is typically used in a negative sense, describing a pathological or excessive need for attention or admiration that does not take into account the feelings, opinions, or preferences of other people.<ref>{{Cite web |title=StackPath |url=https://www.healthyplace.com/personality-disorders/malignant-self-love/narcissists-narcissistic-supply-and-sources-of-supply |access-date=October 10, 2019 |website=www.healthyplace.com}}[unreliable source?]</ref>
====Narcissistic rage==== The term ''narcissistic rage'' was a concept introduced by [[Heinz Kohut]] in 1972. Narcissistic rage was theorised as a reaction to a perceived threat to a narcissist's [[self-esteem]] or self-worth. Narcissistic rage occurs on a continuum from aloofness, to expressions of mild irritation or annoyance, to serious outbursts, including violent attacks.<ref name="Malmquist_2006">{{cite book | vauthors = Malmquist CP |title=Homicide: A Psychiatric Perspective |publisher=[[American Psychiatric Association]]|location=Washington, D.C.|year=2006 |isbn=978-1-58562-204-7 |pages=181–82}}</ref> Aggression have been found to be highly correlated to personality disorders (PD), pathological narcissism, (PN) narcissistic personality disorder (NPD), and even borderline personality disorder (Théberge & Gamache, 2023).
Narcissistic rage reactions are not necessarily limited to narcissistic personality disorder. They may also be seen in [[catatonic]], [[paranoid delusion]], and depressive episodes.<ref name="Malmquist_2006" />
===Object relations=== In the second half of the 20th century, in contrast to Freud's perspective of megalomania as an obstacle to psychoanalysis, in the US and UK [[Melanie Klein|Kleinian]] psychologists used the [[object relations theory]] to re-evaluate megalomania as a [[defence mechanisms|defence mechanism]].<ref name=":11">{{Cite book| vauthors = Hughes JM |title=From obstacle to ally: the evolution of psychoanalytic practice|date=2004|publisher=Brunner-Routledge|isbn=978-1-58391-890-6 |location=New York|page=175|language=English|oclc=57488252}}</ref> This Kleinian therapeutic approach built upon [[Heinz Kohut]]'s view of narcissistic megalomania as an aspect of normal mental development, by contrast with [[Otto Kernberg]]'s consideration of such grandiosity as a pathological distortion of normal psychological development.<ref name=":11" />
To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed individual who passes blame by [[psychological projection]] and is intolerant of contradictory views and opinions; is apathetic towards the emotional, mental, and psychological needs of other people; and is indifferent to the negative effects of their behaviors, whilst insisting that people should see them as an ideal person.<ref>{{cite journal | vauthors = Wright AG, Stepp SD, Scott LN, Hallquist MN, Beeney JE, Lazarus SA, Pilkonis PA | title = The effect of pathological narcissism on interpersonal and affective processes in social interactions | journal = Journal of Abnormal Psychology | volume = 126 | issue = 7 | pages = 898–910 | date = October 2017 | pmid = 29106275 | pmc = 5679127 | doi = 10.1037/abn0000286 | s2cid = 46847228 }}</ref> The merging of the terms "inflated self-concept" and "actual self''"'' is evident in later research on the grandiosity component of narcissistic personality disorder, along with incorporating the defence mechanisms of [[idealization and devaluation]] and of [[denial]].<ref name="pmid16937998">{{cite journal | vauthors = Siegel JP | title = Dyadic splitting in partner relational disorders | journal = Journal of Family Psychology | volume = 20 | issue = 3 | pages = 418–422 | date = September 2006 | pmid = 16937998 | doi = 10.1037/0893-3200.20.3.418 }}</ref>
===Modern diagnosis=== In the [[ICD-10 classification of personality disorders]], previous to the newer ICD-11, narcissistic personality disorder is listed under the category of ''[[other specific personality disorders]]'' ({{ICD10|F60.8}}),<ref>{{Cite journal |last1=Day |first1=Nicholas J. S. |last2=Green |first2=Ava |last3=Denmeade |first3=Georgia |last4=Bach |first4=Bo |last5=Grenyer |first5=Brin F. S. |date=August 2024 |title=Narcissistic personality disorder in the ICD-11: Severity and trait profiles of grandiosity and vulnerability |journal=Journal of Clinical Psychology |language=en |volume=80 |issue=8 |pages=1917–1936 |doi=10.1002/jclp.23701 |issn=0021-9762 |pmid=38742471 |quote=In the ICD‐10 (World Health Organization, 1992) a number of specific personality disorders are listed (e.g., paranoid, schizoid, histrionic, etc.) along with short descriptions of their key features, however narcissism is included by name only under "Other specific personality disorders" with descriptive content entirely absent (Levy et al., 2013). |doi-access=free}}</ref> meaning the [[ICD-10]] required that cases otherwise described as NPD in the DSM-5 would only need to meet a general set of diagnostic criteria.<ref>WHO (2010) [http://apps.who.int/classifications/icd10/browse/2010/en#/F60 ICD-10: Specific Personality Disorders] {{Webarchive|url=https://web.archive.org/web/20141102133725/http://apps.who.int/classifications/icd10/browse/2010/en#/F60|date=2 November 2014}}</ref>{{Original research inline|date=June 2025}}
The extent of controversy about narcissism was on display when the committee on personality disorders for the 5th Edition (2013) of the [[Diagnostic and Statistical Manual of Mental Disorders]] recommended the removal of Narcissistic Personality from the manual. A contentious three-year debate unfolded in the clinical community with one of the sharpest critics being [[John G. Gunderson|John Gunderson]], who led the DSM personality disorders committee for the 4th edition of the manual.<ref>{{cite news |title=A Fate That Narcissists Will Hate: Being Ignored |url=https://www.nytimes.com/2010/11/30/health/views/30mind.html |access-date=9 November 2010 |work=[[The New York Times]] |vauthors=Zanor C}}</ref>
The [[American Psychiatric Association]]'s (APA) formulation, description, and definition of narcissistic personality disorder, as published in the [[DSM-IV-TR|''Diagnostic and Statistical Manual of Mental Disorders'', Fourth Ed., Text Revision]] (DSM-IV-TR, 2000), was criticised by clinicians as inadequately describing the range and complexity of the personality disorder that is NPD. That it is excessively focused upon "the narcissistic individual's external, symptomatic, or social interpersonal patterns – at the expense of ... internal complexity and individual suffering", which reduced the clinical utility of the NPD definition in the DSM-IV-TR.<ref name="Ronningstam_2010" />
In revising the diagnostic criteria for personality disorders, the work group for the list of "Personality and Personality Disorders" proposed the elimination of narcissistic personality disorder (NPD) as a distinct entry in the DSM-5, and thus replaced a categorical approach to NPD with a dimensional approach, which is based upon the severity of the dysfunctional-personality-trait domains.<ref>{{cite web |date=2010-02-13 |title=DSM-5: Proposed Revisions: Personality and Personality Disorders |url=http://www.dsm5.org/ProposedRevisions/Pages/PersonalityandPersonalityDisorders.aspx |url-status=live |archive-url=https://web.archive.org/web/20101203170307/http://www.dsm5.org/PROPOSEDREVISIONS/Pages/PersonalityandPersonalityDisorders.aspx |archive-date=3 December 2010 |publisher=American Psychiatric Association |df=dmy-all}}</ref><ref name="pmid202239592">{{cite journal |vauthors=Holden C |date=March 2010 |title=Psychiatry. APA seeks to overhaul personality disorder diagnoses |journal=Science |volume=327 |issue=5971 |page=1314 |doi=10.1126/science.327.5971.1314 |pmid=20223959}}</ref> Clinicians critical of the DSM-5 revision characterized the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist", which is of limited usefulness in clinical practice.<ref>{{cite journal |display-authors=6 |vauthors=Shedler J, Beck A, Fonagy P, Gabbard GO, Gunderson J, Kernberg O, Michels R, Westen D |date=September 2010 |title=Personality disorders in DSM-5 |journal=The American Journal of Psychiatry |volume=167 |issue=9 |pages=1026–1028 |doi=10.1176/appi.ajp.2010.10050746 |pmid=20826853}}</ref> Despite the reintroduction of the NPD entry, the APA's re-formulation, re-description, and re-definition of NPD, towards a dimensional view based upon personality traits, remains in the list of personality disorders of the DSM-5.
==Controversy== A 2011 study concluded that narcissism should be conceived as personality dimensions pertinent to the full range of personality disorders, rather than as a distinct diagnostic category.<ref>{{cite journal | vauthors = Karterud S, Øien M, Pedersen G | title = Validity aspects of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, narcissistic personality disorder construct | journal = Comprehensive Psychiatry | volume = 52 | issue = 5 | pages = 517–526 | date = September 2011 | pmid = 21193181 | doi = 10.1016/j.comppsych.2010.11.001 }}</ref> In a 2012 literature review about NPD, the researchers concluded that narcissistic personality disorder "shows [[nosological]] inconsistency, and that its consideration as a trait domain needed further research would be strongly beneficial to the field."<ref>{{cite journal | vauthors = Alarcón RD, Sarabia S | title = Debates on the narcissism conundrum: trait, domain, dimension, type, or disorder? | journal = The Journal of Nervous and Mental Disease | volume = 200 | issue = 1 | pages = 16–25 | date = January 2012 | pmid = 22210358 | doi = 10.1097/NMD.0b013e31823e6795 | s2cid = 24405066 }}</ref>
==In popular culture== * [[To Die For#Cast|Suzanne Stone-Maretto]], [[Nicole Kidman]]'s character in the film ''[[To Die For]]'' (1995), wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she "was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder... had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder".<ref>{{cite journal | vauthors = Hesse M, Schliewe S, Thomsen RR | title = Rating of personality disorder features in popular movie characters | journal = BMC Psychiatry | volume = 5 | issue = 1 | article-number = 45 | date = December 2005 | pmid = 16336663 | pmc = 1325244 | doi = 10.1186/1471-244X-5-45 | doi-access = free }}</ref> * [[Jay Gatsby]], the eponymous character of [[F. Scott Fitzgerald]]'s novel ''[[The Great Gatsby]]'' (1925), "an archetype of self-made American men seeking to join [[Upper class|high society]]", has been described by English professor Giles Mitchell as a "pathological narcissist" for whom the "[[Ego ideal|ego-ideal]]" has become "inflated and destructive" and whose "grandiose lies, poor sense of reality, sense of entitlement, and exploitive treatment of others" conspire toward his own demise.<ref>{{cite journal | vauthors = Mitchell G | title = The Great Narcissist: A Study of Fitzgerald's Gatsby | journal = American Journal of Psychoanalysis | volume = 51 | issue = 4 | pages = 87–96 | date = 1991 | doi = 10.1007/BF01251033 | pmid = 1799200 }}</ref><ref>{{cite web|url=http://fitzgerald.narod.ru/critics-eng/mitchell-narcissist.html|title=The Great Narcissist: A Study of Fitzgerald's Gatsby | author = Giles Mitchell |website=fitzgerald.narod.ru|access-date=22 October 2017}}</ref>
==See also== {{portal|Psychology|Psychiatry}}
* [[Identity disturbance]] * [[Messiah complex]] * [[Narcissistic neurosis]] * [[Superiority complex]] * [[True self and false self]]
==References== {{Reflist}}
==Further reading== {{refbegin|30em}} * {{cite book |title=Narcissism: denial of the true self |vauthors=Lowen A |date=1997 |publisher=Simon & Schuster |isbn=978-0-7432-5543-1 |location=New York |author-link=Alexander Lowen}} * {{cite book |title=Rethinking narcissism: the bad-and surprising good-about feeling special |vauthors=Malkin C |date=2015 |publisher=Harper Wave |isbn=978-0-06-234810-4 |location=New York}} * {{cite book |title=The Narcissistic and Borderline Disorders: An Integrated Developmental Approach |vauthors=Masterson JF |publisher=Routledge |year=1981 |isbn=978-0-87630-292-7 |location=London |doi=10.4324/9780203776148 |lccn=81038540}} * {{cite book |title=Essential papers on narcissism |vauthors=Morrison AP |date=1986 |publisher=New York University Press |isbn=978-0-8147-5395-8 |series=Essential Papers in Psychoanalysis |volume=13 |location=New York}} * {{cite book |title=Shame: The Underside of Narcissism |vauthors=Morrison AP |date=1989 |publisher=Analytic Press |isbn=978-1-317-77161-6 |location=New York}} * {{cite book |title=Maintaining relationships through communication: relational, contextual, and cultural variations |vauthors=Shaw D |date=2003 |publisher=Lawrence Erlbaum Associates |isbn=978-0-8058-3990-6 |location=Mahwah, NJ}} * {{cite book |title=Narcissism: Behind the Mask |vauthors=Thomas D |date=2010 |publisher=Book Guild |isbn=978-1-84624-506-0 |location=Sussex}} {{refend}}
==External links== {{Commons}}
* [https://psychiatryonline.org/doi/pdf/10.1176/appi.focus.11.2.189 Alternative DSM-5 Model for Personality Disorders] (with AMPD definition of NPD)
{{Medical condition classification and resources | DiseasesDB = | ICD10 = {{ICD10|F|60|8|f|60}} | ICD9 = {{ICD9|301.81}} | ICDO = | OMIM = | MedlinePlus = 000934 | eMedicineTopic = | MeshID = D010554 | ICD11 = {{ICD11|6D10}} }} {{ICD-10 personality disorders}} {{Narcissism}} {{Digital media use and mental health}} {{Authority control}}
[[Category:Dark triad]] [[Category:Cluster B personality disorders]] [[Category:Narcissism]] [[Category:Psychoanalytic terminology]] [[Category:Wikipedia medicine articles ready to translate]] [[Category:Wikipedia neurology articles ready to translate]]