NPD Explained: Signs, Types, and Treatment Options for Narcissistic Personality Disorder

What Is Narcissistic Personality Disorder?

Narcissistic personality disorder falls into the category of Cluster B personality disorders, characterized by a pervasive pattern of grandiosity, a need for excessive admiration, and a lack of empathy for others — patterns that begin by early adulthood and are present in most areas of life.[1] Like all personality disorders, NPD involves an enduring and pervasive pattern of thinking, feeling, and behaving that is typically ego-syntonic, meaning the patterns feel right and justified to the person experiencing them, making the need for treatment difficult to see.[2] 

The American Psychiatric Association’s DSM-5  has nine specific criteria for diagnosis, five of which must be met for a diagnosis. What cannot be conveyed by criteria, however, is the underlying experience of NPD: low self-esteem, being highly sensitive to perceived criticism, and the distress that drives narcissistic behavior. The estimated prevalence of NPD is anywhere from  1-2%  of the population, and is diagnosed more commonly in males than females[3]

Types of Narcissistic Personality Disorder

Even though NPD is considered to be one diagnosis in the DSM-5, clinicians and researchers recognize meaningfully different presentations that delineate what treatment should be offered. The most common are listed below:

• Grandiose (overt) narcissism — The grandiose presentation most closely aligns with the cultural prototype of a narcissist. This presentation is characterized by self-promotion, dominance, a sense of entitlement, and is often characterized by outwardly assertive or aggressive interpersonal styles.
• Vulnerable (covert) narcissism — While this presentation is not as easily identifiable due to the level of covert behavior, it is equally as significant as the grandiose presentation. The vulnerable presentation is marked by hypersensitivity to criticism and social withdrawal, yet will project a sense of superiority along with a chronic sense of being treated unfairly or misunderstood.
• Malignant narcissism — This extremely severe presentation is a combination of narcissistic traits with antisocial behavior, aggression, and paranoia; associated with the greatest interpersonal harm to others and the most challenging clinical picture.

Identifying which type of NPD is present helps inform clinical practice and the focus of the therapeutic process.

What Causes NPD?

NPD occurs as a result of both early life experiences and biological predisposition.

• Early experience — Early life experiences, including both excessive praise and neglect or abuse by caregivers, have been associated with the development of narcissistic traits.[4]
• Attachment disturbance — Insecure attachment in early relationships, particularly with caregivers who were inconsistent, emotionally unavailable, or excessively critical, is a significant developmental risk factor.[5]
• Genetics and temperament — NPD involves heritable traits, including being highly sensitive to social comparisons, reward-seeking, and a high level of emotional reactivity.[6]
• Cultural and social environments — Environments that praise narcissistic tendencies, equate self-value with accomplishment, and lack the ability to cultivate empathy can reinforce the development of NPD features.[7]

Symptoms of NPD

NPD symptoms can be grouped into themes of relational difficulties, self-importance, and entitlement:

• • Grandiose sense of self-importance — Exaggeration of personal success and ability, and expecting others to recognize their superiority regardless of proof.
  • Preoccupation with power  — Preoccupied with fantasies of unlimited success, wealth, power, and ideal relationships.
  • Entitlement — The feeling that others owe them something, or that they should be treated better than others because they are more deserving.
  • Interpersonally exploitative — The tendency to use others in order to achieve their own goals.
  • Lack of empathy — Inability or unwillingness to understand the feelings or needs of other people.
  • Envy — The belief that others are envious of them, or being envious of others.
  • Arrogance and haughtiness — These traits can be either explicit or implicit.

• Excessive need for validation and admiration — Needing constant validation and admiration from others and feeling distressed, rejected, or unstable when it isn’t received

• Belief that they are “special” — Believing they can only be understood by other special or high-status people.

NPD presents differently depending on the type of presentation and the person, so accurate assessment is critical for developing a successful treatment plan.

How NPD Affects Daily Life and Relationships

Narcissistic personality disorder significantly affects the interactions a person with NPD has with their family, friends, and co-workers. Many of the behaviors associated with NPD, such as entitlement, lack of empathy, and exploitation, cause a negative dynamic, creating relationships fraught with significant pain and challenge for all parties involved.

For the person with NPD, the condition feels like chronic dissatisfaction, a persistent sense that they are not receiving recognition for their greatness, that others are failing them, and that the world does not reflect their self-importance. Beneath this, though, people with NPD possess little self-worth and are in an extremely vulnerable state. The combination of grandiosity and lack of self-worth makes it extremely difficult for people with NPD to relate genuinely to others, as well as engage in self-reflection.

Those who are in a relationship with a person with NPD typically feel invisible, devalued, and exploited. One of the many advantages of family therapy in the context of NPD is that it not only provides support to the person with NPD but also helps family members cope with these particular challenges together.

When to Seek Professional Help

The ego-syntonic nature of NPD leads many people with the condition to be unaware of their problematic behavior. Most often, people receive a diagnosis of NPD by way of the following situations:

• Having consistent difficulties in interpersonal relationships
• Developing chronic depression, anxiety, or substance abuse
• Major life changes, such as ending a relationship or employment, or the death of a loved one, that disrupt key sources of validation, leading to worsening symptoms
• Being confronted with their NPD behaviors by someone significant in their lives, and being open to the idea of being treated for the disorder
• Not being able to ignore their internal experience of stress, emptiness, and dissatisfaction

NPD Treatment at Helios West Palm

NPD treatment requires care focused on the underlying vulnerabilities of the patient, as well as skill and patience to develop a long-term working alliance. A comprehensive psychiatric assessment and individualized treatment plan create the foundation of NPD treatment at Helios West Palm.

The primary treatment for developing self-awareness, emotional depth, and authentic relationships is individual therapy.[8] The use of psychodynamic psychotherapy and mentalization-based psychotherapy addresses the early life experiences and early relationships that form the foundation of NPD behaviors.

Benefits of NPD Treatment

With sustained engagement in evidence-based treatment, meaningful change is achievable for people with NPD. Benefits include:

• Developing self-awareness of their behaviors, actions, and the effect of their behaviors on others
• Creating a self-worth based on internal validation instead of external validation
• Developing the ability to be more empathetic to the feelings and experiences of others, and an understanding of how their actions affect others
• Reduced reactivity and more adaptive methods of coping with emotions
• Improvement of both daily functioning and interpersonal functioning
• Better management of co-occurring conditions like depression and anxiety
• A more truthful and satisfying relationship with oneself and others