Narcissistic personality disorder (NPD)

Personality disorders are enduring patterns of thinking, feeling and relating to others that differ from cultural expectations, are inflexible and cause distress or difficulties. In narcissistic personality disorder, these patterns center on self-image: a need to feel special, admired and superior, combined with sensitivity to criticism and difficulty recognizing others' needs.

Beneath the confident exterior, many people with NPD have a vulnerable self-esteem that depends heavily on external validation. Criticism or perceived rejection can trigger shame, anger or withdrawal.

The word "narcissist" is widely used online, often to describe anyone who behaves selfishly. A diagnosis of NPD, however, can only be made by a qualified mental health professional after a careful assessment. It is a clinical condition, not an insult.

Common features of NPD include:

• A grandiose sense of self-importance or exaggerating achievements
• Fantasies of unlimited success, power, brilliance or ideal love
• Believing they are special and should only associate with high-status people
• A strong need for admiration
• A sense of entitlement to special treatment
• Taking advantage of others to reach their goals
• Lack of empathy or difficulty recognizing others' feelings
• Envy of others or belief that others envy them
• Arrogant or haughty behavior

Having a few of these narcissistic traits at times is part of being human. NPD involves a persistent pattern across many situations that causes real harm to relationships, work or wellbeing.

Clinicians and researchers often distinguish between two presentations. Overt or grandiose narcissism is the more familiar type: outwardly confident, attention-seeking and dominant.

Covert or vulnerable narcissism is less obvious. A covert narcissist may appear shy, insecure or self-critical, yet still feel entitled, deeply resent others' success and be very sensitive to criticism. They may feel chronically underappreciated and react with sulking, passive-aggression or withdrawal rather than open anger.

Many people show a mix of both styles at different times. NPD also commonly occurs alongside depression, anxiety, substance use or other personality disorders, which can make it harder to recognize.

The causes of NPD are not fully understood, but likely involve a mix of:

• Genetic and temperamental factors
• Early experiences, such as excessive criticism, neglect or, in contrast, excessive praise without realistic feedback
• Inconsistent caregiving or conditional love
• Cultural and family environments that strongly value status and appearance

No single factor causes NPD, and people with these early experiences do not necessarily develop it.

People with NPD often seek help for depression, relationship problems, work difficulties or a crisis rather than for narcissism itself. Psychotherapy is the main treatment. Approaches with some evidence include transference-focused psychotherapy, mentalization-based treatment, schema therapy and other psychodynamic approaches. These help people understand their emotional reactions, develop more stable self-esteem and relate to others with greater empathy.

Therapy can be challenging because criticism may feel threatening, but change is possible, especially when the person is motivated. There is no medication for NPD itself, but a psychiatrist may treat co-occurring conditions such as depression or anxiety.

If someone close to you shows strong narcissistic traits, it can be exhausting and confusing. Strategies that may help include:

• Setting clear, consistent boundaries
• Avoiding arguments aimed at getting them to admit fault
• Focusing on what you can control: your responses and choices
• Keeping supportive relationships outside this connection
• Seeking therapy for yourself to process the impact

Psychologists, clinical psychologists, psychiatrists and couples or family therapists can help both people with NPD and those affected by it. If a relationship involves emotional abuse, threats or violence, prioritize your safety and contact domestic violence services, or call 911 or your local emergency number in an emergency.