Narcissistic personality disorder: identifying, diagnosing and treating a narcissist

By Cristiano Antonino On Jan 27, 2023

Narcissistic personality disorder is characterised by a pervasive pattern of grandiosity, need for adulation/admiration, and lack of empathy, and the diagnosis is made on the basis of clinical criteria

What is narcissistic personality disorder?

The exact and scientific terminology is: narcissistic personality disorder, which can be found in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), the only terms narcissism or pathological narcissism are used in common parlance, for brevity but not by the scientific community.

Narcissism is described in the DSM-5 as a personality disorder of the narcissistic type.

Like all mental disorders, those affected can be both women and men.

It is very important to remember that the diagnosis of narcissistic personality disorder can only be made and certified by a psychologist and psychiatrist (physician).

To be diagnosed with this disorder, an individual must fulfil five or more of the following criteria:

Has high self-esteem or an excessive sense of importance.
Preoccupied with fantasies of unlimited success, power, beauty, love or fitness.
Constant need for admiration.
Believes he is special or unique and that only special or unique people can understand or associate with him.
Has a sense of entitlement. Firmly believes he is entitled to favours or special treatment from others.
He uses others for his own purposes.
Does not show empathy towards others.
He envies others or thinks others are envious of him.
Shows arrogance, cockiness, or has contemptuous behaviour.

Differences between healthy narcissism, narcissistic traits and narcissistic personality disorder

Healthy narcissism is a positive trait in which a person has good self-esteem and self-confidence.

They are able to love themselves without putting others in second place and are also able to accept their own flaws.

Narcissistic traits, on the other hand, are personality traits that include a great need for attention and admiration, a lack of empathy for others, and a tendency to overestimate oneself.

These traits may be present in different measures and may vary from person to person.

For example, a person with moderate narcissistic traits may be able to have healthy relationships and have good self-esteem, whereas a person with stronger narcissistic traits may have difficulty relating to others and have a high need for attention and admiration.

Narcissistic personality disorder, also known as NPD, is a severe mental disorder in which a person has pathological and persistent narcissistic traits

These people have hypertrophic grandiosity, a high need for attention and admiration, a lack of empathy for others, and a tendency to overestimate themselves.

These traits are so intense that they cause significant problems in the person’s personal and professional life, and can interfere with the ability to have healthy relationships and to function adequately in everyday life.

What are the various types of narcissism?

In the field of clinical psychology, there are three types of narcissism

overt narcissism,
covert narcissism,
malignant narcissism.

Overt narcissism: is characterised by an explicit and often excessive display of the ego, strong self-esteem and a need for attention and admiration. People with overt narcissism are often seen as arrogant, self-centred and often seek to dominate others.

Covert narcissism: is characterised by an implicit display of the ego, low self-esteem and a need for attention and admiration. People with covert narcissism are often seen as insecure, dissatisfied and dependent on others for their self-esteem.

Malignant narcissism: is characterised by a combination of overt and covert narcissistic traits and the presence of cruelty, manipulation and distrust of others. People with malignant narcissism are often seen as dangerous and harmful to others and can cause significant damage to relationships. They are also the ones who kill.

Differential diagnosis with other disorders

Differential diagnosis in psychology is important because many mental disorders have similar symptoms and it can be difficult to determine the correct diagnosis without careful evaluation.

For example, symptoms of anxiety may be similar to those of panic, and differential diagnosis is necessary to determine whether an individual suffers from an anxiety disorder, a panic disorder, or whether they are in comorbidity.

The differential diagnosis of narcissism in psychology and psychiatry involves evaluating the symptoms and traits present in an individual to determine whether the symptoms are due to narcissistic personality disorder (NPD), whether they are present in other mental disorders, whether there is an influence from substance use/abuse or another medical condition.

The differential diagnosis for NPD can be made with respect to other personality disorders, such as borderline personality disorder or antisocial personality disorder.

Furthermore, the symptoms of NPD may be similar to those of bipolar disorder or manic-depressive disorder, and may be confused with these disorders.

The differential diagnosis of narcissism with other personality disorders such as borderline personality disorder, bipolar disorder, antisocial personality disorder and histrionic personality disorder can be difficult, as these disorders may present similar symptoms.

However, there are some key differences that can help distinguish between these disorders:

Borderline personality disorder: people with this disorder present high emotional, relational and self-image instability, and a tendency to experience strong negative emotions such as anger, sadness and fear of abandonment. People with NPD have greater emotional stability and less impulsivity and relational instability.

Bipolar disorder: people with this disorder present episodes of excessively high or low mood, accompanied by alterations in energy level, activity and ability to concentrate. People with NPD do not show these extreme mood symptoms.

Antisocial personality disorder: people with this disorder have a tendency to violate the rights of others and have a poor ability to conform to social and legal norms. People with NPD are less prone to violence and criminality.

Histrionic personality disorder: people with this disorder have a constant need for attention and admiration, and tend to be dramatic, seductive and unpredictable. People with NPD are less prone to be as dramatic and seductive, but may have a similar need for attention and admiration.

In summary, the differential diagnosis of NPD with these personality disorders requires a careful assessment of the symptoms and traits present in an individual and a comparative analysis with the diagnostic criteria of these disorders.

An experienced professional, such as a psychiatrist or psychologist, will use this information to determine the most appropriate diagnosis and to direct the patient to the appropriate treatment.

Causes of narcissistic personality disorder

The exact causes of narcissistic personality disorder (NPD) are not yet fully understood, but are believed to be due to a combination of genetic, environmental and psychological factors.

Genetic factors: some studies have suggested that there may be a genetic component in the development of NPD, although researchers have not yet been able to identify specific genes or mechanisms that are responsible.
Environmental factors: negative emotional and relational experiences during childhood, such as lack of love and support, neglect, physical or emotional abuse, or overindulgence by parents, may contribute to the development of NPD.
Psychological factors: some theories suggest that people with NPD may have a distorted self-image, a sense of inferiority or low self-esteem, and that they may use narcissistic behaviour as a defence mechanism to cover up these feelings. Furthermore, studies have shown that people with NPD often have a tendency to idealise some people (parents, reference figures) and demonise others; this may be an explanation for their difficulty in having healthy relationships.

In general, it is important to note that the causes of narcissistic personality disorder are multifactorial and can vary from person to person: understanding the causes is important for developing effective treatments for this disorder.

Narcissistic behaviour, the characteristics

In understanding narcissistic behaviour, it is important to consider splitting, projective identification and denial.

Splitting

Splitting is a defence mechanism used by people with narcissistic personality disorder (NPD) to protect themselves from negative emotions and unwanted thoughts.

Splitting consists of the separation or dissociation between different parts of the self, so that negative emotions or unwanted aspects of the personality can be pushed aside and not dealt with.

Concrete examples of splitting in NPD may include:

Idealisation and devaluation: A person with NPD may idealise certain people, e.g. parents or reference figures, and attribute perfect qualities to them, while at the same time demonising other people, attributing negative and negative qualities to them. Or he/she may ‘now’ idealise and ‘later’ devalue the party for no apparent reason.
A person with NPD idealises their partner at the beginning of the relationship, seeing her as perfect and ideal, but then devalues her when she no longer fits this ideal image.
A person with NPD may dissociate their positive and negative feelings towards their partner, e.g. they may love their partner when they find her attractive or useful for their social status, but hate her when she no longer meets these criteria.
A person with NPD may have a part of themselves that loves their partner and wants the relationship to work, and another part that hates them and wants the relationship to end; this split can cause confusion and uncertainty in the relationship.
Cleavage between one’s inner parts: A person with NPD may have a part of self that is great and wants to be admired, another part that is insecure and fears rejection, and another part that is angry and vindictive. This split can be used to avoid being vulnerable and to protect the self-image.

Projective identification

Projective identification is a defence mechanism in which a person with narcissistic personality disorder (NPD) projects their negative traits or insecurities onto another person, often a partner.

In this way, the person with NPD can maintain a positive self-image and avoid facing their own insecurities or negative traits.

Concrete examples of projective identification in a romantic relationship may include:

Constantly accusing one’s partner of being jealous or possessive, when in reality they are the ones who are jealous and possessive.
Accusing one’s partner of being superficial or only interested in money, when in reality it is they who are superficial and only interested in money.
Denying the reality of their own negative behaviour towards their partner, e.g. they may deny having treated her in a cruel or manipulative way, and blame their partner for any problems in the relationship.
Accusing one’s partner of being emotionally distant or uninvolved, when in reality it is they who are emotionally distant and uninvolved in the relationship.
Accusing one’s partner of being unattractive or uninteresting, when in reality it is they who have problems with their body image or personality.

Denial

Denial is a defence mechanism used by people with narcissistic personality disorder (NPD) to avoid facing reality, their responsibilities and their negative emotions.

Denial consists of rejecting or denying reality when it does not fit one’s self-image or expectations.

Concrete examples of denial in NPD in relation to one’s partner may include:

Denial of hurting one’s partner’s feelings, even if evidence indicates otherwise.
Denying being jealous or possessive, even if one’s partner has repeatedly pointed out these behaviours.
Denying having problems with self-esteem or body image, even though one’s partner has repeatedly pointed out these behaviours.
Denying having made a mistake or having made a wrong decision, even if reality proves otherwise.

In general, these defence mechanisms are used by people with NPD to avoid facing their own insecurities and negative traits.

Envy, anger, substance abuse and violence

Envy, anger, substance abuse and violence are all common traits or behaviours associated with narcissistic personality disorder (NPD).

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Envy is a feeling often present in people with NPD, which may stem from their distorted self-perception and their inability to accept their own inadequacies. They may envy others for their achievements, beauty, popularity, wealth, and may feel inferior to them. Envy may drive people with NPD to try to humiliate, criticise or compete with others in order to feel superior.

Anger is another common emotion in people with NPD, which may stem from their perception of being undervalued or despised by others. They may easily feel offended or threatened and may react with anger or revenge. Anger may also be used as a defence mechanism to hide one’s insecurities or vulnerability.

Substance abuse is a common behaviour in people with NPD, who may use drugs or alcohol to manage their negative emotions, improve self-image or avoid facing real problems.

Violence is an extreme behaviour associated with NPD, which may result from the perception of being threatened or despised by others.

People with NPD may become aggressive or violent to impose their power or to get what they want, even if it means causing harm to other people.

In general, envy, anger, substance abuse, and violence are all common behaviours or emotions associated with NPD, which can result from distorted self-perception and difficulty managing negative emotions.

These behaviours can cause significant damage to the relationships and mental health of those involved.

In addition, these behaviours can also be used as defence mechanisms to mask the insecurities and vulnerabilities of people with NPD, preventing them from dealing with real problems and improving themselves and their relationships.

For this reason, it is important that people with NPD receive psychological or psychiatric treatment to help them recognise and manage these behaviours and improve their self-perception and interpersonal relationships.

Therapy in narcissistic personality disorder

Why does the narcissist not go to therapy?

There are several reasons why a person with narcissistic personality disorder (NPD) may be reluctant to go to therapy:

The narcissist may deny having a problem and needing help. Denial is a common defence mechanism in NPD, and can prevent people from recognising their problems and asking for help.
They may feel superior to others and not see the need to change. May think that others are the ones who need to change and not them.
May have a positive self-image and not see the reason to change. They may think that there is nothing wrong with them and that others are the ones with problems.
The narcissist may fear losing control. Therapy involves opening up about themselves and expressing their emotions, and this may be seen as a threat to their self-image and control.
They may have difficulty establishing trusting relationships with others and difficulty relating to others, which may make it difficult for them to open up to a therapist

Therapy for narcissism

There are several therapies that can be used to treat narcissistic personality disorder (NPD), including:

Cognitive behavioural psychotherapy (CBT): a form of psychotherapy that focuses on identifying and changing dysfunctional thoughts, emotions and behaviour. CBT can help people with NPD develop a more realistic perception of themselves and others, improve interpersonal relationships and manage negative emotions.
Psychodynamic psychotherapy: a form of psychotherapy that focuses on the analysis of unconscious conflicts and relational dynamics. Psychodynamic psychotherapy can help people with NPD understand the origins of their personality problems and develop greater self-awareness and a greater ability to establish healthy relationships.
Group psychotherapy: a form of therapy involving a group of people with similar problems who meet regularly to discuss their problems and support each other. Group therapy can help people with NPD develop a greater understanding of others and a greater ability to establish healthy relationships.

The time needed for improvement and change in therapy for narcissistic personality disorder (NPD) varies from person to person and depends on a number of factors, including the severity of symptoms, the patient’s motivation for change, and the presence of other mental health conditions.

In general, treatment for NPD can take a long time, often years, because personality is a constant and ingrained in the person, and therapy must work on this basis.

Change can be gradual and require a lot of time and effort.

That said, some people may notice significant improvements in their symptoms in a shorter period of time, especially if they are highly motivated and willing to work hard in therapy.

Others may not notice significant improvements until after a long period of time.

In any case, it is important to remember that the goal of therapy is not only to improve symptoms but also to help the person live a more satisfying and fulfilling life; this process requires time and dedication on the part of both therapist and patient.

Medications can be used as part of the treatment for narcissistic personality disorder (NPD), but there are no specific medications for the treatment of NPD.

Instead, drugs can be used to treat symptoms associated with NPD, such as depression, anxiety, anger, sexual dysfunction and paraphilias.

“There cannot be a God because, if there were one, I would not believe it was not me.” – Friedrich Wilhelm Nietzsche

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