Narcissistic personality disorder

Narcissistic personality disorder
Narcissus (1597–99) by Caravaggio; the man in love with his own reflection
Specialty	Psychiatry, clinical psychology
Symptoms	Exaggerated feelings of self-importance, excessive craving for admiration, reduced levels of empathy[1][2]
Usual onset	Early adulthood[2]
Duration	Long term[2]
Causes	A combination of genetic and environmental factors. Social theories of NPD are weak and causality is unclear.
Diagnostic method	Based on symptoms
Differential diagnosis	Bipolar disorder, mania and hypomania, antisocial personality disorder, substance abuse, borderline personality disorder, histrionic personality disorder,[1] grandiose delusions.
Treatment	Psychotherapy, pharmaceuticals for comorbid disorders[1]
Frequency	6.2%citations

Narcissistic personality disorder (NPD) is a personality disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a diminished ability to empathize with other people's feelings. Narcissistic personality disorder is one of the sub-types of the broader category known as personality disorders.^[1][2] It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability.^[1]

Personality disorders are a class of mental disorders characterized by enduring and inflexible maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by any culture. These patterns develop by early adulthood, and are associated with significant distress or impairment.^[3][4][5] Criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

There is no standard treatment for NPD.^[6][7] Its high comorbidity with other mental disorders influences treatment choice and outcomes.^[6] Psychotherapeutic treatments generally fall into two categories: psychoanalytic/psychodynamic and cognitive behavioral therapy, with growing support for integration of both in therapy.^[8][9] However, there is an almost complete lack of studies determining the effectiveness of treatments.^[7] One's subjective experience of the mental disorder, as well as their agreement to and level of engagement with treatment, are highly dependent on their motivation to change.^[10]

Despite outward signs of grandiosity, many people with NPD struggle with symptoms of intense shame, worthlessness, low self-compassion, and self-loathing.^[11][12] Their view of themselves is extremely malleable and dependent on others' opinions of them. They are also hypersensitive to criticism and possess an intense need for admiration.^[13][14][15] People with NPD gain self-worth and meaning through this admiration.^[16][17] Individuals with NPD are often motivated to achieve their goals, status, improvement, and perfectionism, and to ignore relationships or avoid situations due to fears of incompetence, failure, worthlessness, inferiority, shame, humiliation, and losing control.^[12][6]

People with NPD will try to gain social status and approval in an attempt to avoid and combat these feelings,^[18] often by exaggerating their skills, accomplishments, and their degree of intimacy with people they consider high-status.^[19][20][21] Alongside this, they may have difficulty accepting help,^[22] vengeful fantasies, a sense of entitlement,^[20][23] and they may feign humility. They are more likely to try forms of plastic surgery due to a desire to gain attention and to be seen as beautiful.^[2][24][25] A sense of personal superiority may lead them to monopolize conversations, look down on others or to become impatient and disdainful when other persons talk about themselves.^[2][11] Drastic shifts in levels of self-esteem can result in a significantly decreased ability to regulate emotions.^[26]

Patients with NPD have an impaired ability to recognize facial expressions or mimic emotions, as well as a lower capacity for emotional empathy and emotional intelligence.^[27][28] However they do not display a compromised capacity for cognitive empathy or an impaired theory of mind, which are the abilities to understand others' feelings and attribute mental states to oneself or others respectively.^[29] They may also have difficulty relating to others’ experiences and being emotionally vulnerable.^[30] People with NPD are less likely to engage in prosocial behavior.^[30] They can still act in selfless ways to improve others' perceptions of them, advance their social status, or if explicitly told to.^[31] Despite these characteristics, they are more likely to overestimate their capacity for empathy.^[32]

It is common for people with NPD to have difficult relationships.^{[33][34][35][36]} Narcissists may disrespect others' boundaries or idealize and devalue them. They commonly keep people emotionally distant, and project, deny,^[37] or split. Narcissists respond with anger and hostility towards rejection,^[38][33][39] and can degrade, insult, or blame others who disagree with them.^[40][41]

They generally lack self-awareness, and will have a difficult time understanding their own traits and narcissistic tendencies, either due to a belief that NPD characteristics do not apply to them, or due to a refusal to accept or endorse negative characteristics in an attempt to maintain a positive self image.^[42][43] Narcissists can have difficulty seeing multiple perspectives on issues and might engage in black and white thinking.^[44] Despite this, people with NPD will often feel as they are skilled at accurately assessing others' feelings.^[45]

The DSM-5 indicates that: "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."^[2] 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.^[46] 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.^[2][25] 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.^[47]

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes NPD as possessing at least five of the following nine criteria.^[2]

• A grandiose sense of self-importance (exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
• Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
• Believing that they are "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
• Requiring excessive admiration
• A sense of entitlement (unreasonable expectations of especially favorable treatment or automatic compliance with their expectations)
• Being interpersonally exploitative (taking advantage of others to achieve their own ends)
• Lacking empathy (unwilling to recognize or identify with the feelings and needs of others)
• Often being envious of others or believing that others are envious of them
• Showing arrogant, haughty behaviors or attitudes

Within the DSM-5, NPD is a cluster B personality disorder.^[2] Individuals with cluster B personality disorders often appear dramatic, emotional, or erratic.^[2] Narcissistic personality disorder is a mental disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive craving for admiration, and a diminished ability to empathize with others' feelings.^[1][2]

A diagnosis of NPD, like other personality disorders, is made by a qualified healthcare professional in a clinical interview. In the narcissistic personality disorder, there is a fragile sense of self that becomes a view of oneself as exceptional.^[1]

Narcissistic personality disorder usually develops either in youth or in early adulthood.^[2] True symptoms of NPD are pervasive, are apparent in varied social situations, and are rigidly consistent over time. Severe symptoms of NPD can significantly impair the person's mental capabilities to develop meaningful human relationships, such as friendship, kinship, and marriage. Generally, the symptoms of NPD also impair the person's psychological abilities to function socially, either at work or at school, or within important societal settings. The DSM-5 indicates that, in order to qualify as symptomatic of NPD, the person's manifested personality traits must substantially differ from social norms.^[2]

In the International Statistical Classification of Diseases and Related Health Problems, 11th Edition ICD-11 of the World Health Organization (WHO), all personality disorders are diagnosed under a single title called "personality disorder.” The criteria for diagnosis are mainly concerned with assessing dysfunction, distress, and maladaptive behavior. Once a diagnosis has been made, the clinician then can draw upon five trait domains to describe the particular causes of dysfunction, as these have major implications for potential treatments.^[48] NPD, as it currently conceptualised, would correspond more or less entirely to the ICD-11 trait of Dissociality, which includes self-centredness (grandiosity, attention-seeking, entitlement and egocentricity) and lack of empathy (callousness, ruthlessness, manipulativeness, interpersonal exploitativeness, and hostility).^[48][49]

In the previous edition, the ICD-10, narcissistic personality disorder (NPD) is listed under the category of "other specific personality disorders", 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.^[50]

The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders.^[51] 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.^[52] NPD is associated with the occurrence of bipolar disorder and substance use disorders,^[1][25] especially cocaine use disorder.^[2] NPD may also be comorbid or differentiated with the occurrence of other mental disorders, including histrionic personality disorder, borderline personality disorder, antisocial personality disorder, or paranoid personality disorder.^[2] 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.^[2] 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.^[11]

Although the DSM-5 diagnostic criteria for NPD has been viewed as homogeneous, there are a variety of subtypes used for classification of NPD.^[1][57][58] 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.^[8][57] However, none of the subtypes of NPD are recognized in the DSM-5 or in the ICD-11.

Some research has indicated the existence of three subtypes of NPD,^[59] 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.^[60] This group was noted for high levels of comorbid antisocial and paranoid personality disorders, substance abuse, externalizing, unemployment and greater likelihood of violence.^[59][61] 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.^[61]

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. In fact, recent research suggests that vulnerable narcissism is mostly the product of dysfunctional levels of neuroticism.^[62] Vulnerable narcissism is sometimes comorbid with diagnoses of avoidant, borderline and dependent personality disorders.^[59][61]

High-functioning/Exhibitionistic: A third subtype for classifying people with NPD, initially theorized by psychiatrist Glen Gabbard, is termed high functioning or exhibitionistic.^[63][59] 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."^[57] This group has been found to have relatively few psychological issues and high rates of obsessive-compulsive personality disorder, with excessive perfectionism posited as a potential cause for their impairment.^[59]

Oblivious/Hypervigilant: Glen Gabbard described two subtypes of NPD in 1989, later referred to as equivalent to, the grandiose and vulnerable subtypes.^[64][65][63] 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.^[66][67] Individuals who display communal narcissism often seek out positions of power and influence within their groups.

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In the study Disorders of Personality: DSM-IV-TM and Beyond (1996), Theodore Millon suggested five subtypes of NPD, although they did not identify specific treatments per subtype.^[5]

In 1993, James F. Masterson proposed two subtypes for pathological narcissism, exhibitionist and closet.^[68] 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.^[69]

Malignant narcissism, a term first coined in Erich Fromm's 1964 book The Heart of Man: Its Genius for Good and Evil,^[70] is a syndrome consisting of a combination of NPD, antisocial personality disorder, and 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, 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 behaviors), aggression, and sadism.^[71]

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:^[72]

Risk factors for NPD and grandiose/overt and vulnerable/covert subtypes are measured using the 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.^[73]

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.^[73][74]

The PNI scales show significant associations with parasuicidal behavior, suicide attempts, homicidal ideation, and several aspects of psychotherapy utilization.^[75]

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).^[76] Later analysis revealed that the FFNI actually measures three factors:^[77]

1. Agentic Extraversion: an exaggerated sense of self-importance, grandiose fantasies, striving for greatness and acclaim, social dominance and authoritativeness, and exhibitionistic, charming interpersonal conduct.
2. 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.
3. 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 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 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.^[77][78]

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.^[79] Whereas the MCMI measures narcissistic personality disorder (NPD), the NPI measures narcissism as it occurs in the general population; the MCMI is a 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.^[80]

A 2020 study found that females scored significantly higher on vulnerable narcissism than males, but no gender differences were found for grandiose narcissism.^[81]

The cause of narcissistic personality disorder (NPD) is unclear, although there is evidence for a strong biological or genetic underpinning.^[82] Research has found NPD has a strong heritable component.^{[82][83][84][85]} It is unclear if or how much a person's upbringing contributes to the development of NPD, although many speculative theories have been proposed.^{[82][86][87][88]}

Evidence to support social factors in the development of NPD is limited.^[82][88] Some studies have found NPD correlates with permissive and overindulgent parenting in childhood, while others have found correlations with harsh discipline, neglect or abuse.^[82] Findings have been inconsistent, and scientists do not know if these correlations are causal, as these studies do not control for genetic confounding.^[82][88]

This problem of genetic confounding is explained by psychologist Svenn Torgersen in a 2009 review:^[88]

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.^[88]

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).^[89][90][88] 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:^[83]

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.

— Lu & Cai, 2018^[83]

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.^[90]

Neuroscientists have also studied the brains of people with NPD using structural imaging technology.^[91] A 2021 review concluded the most consistent finding among NPD patients is lowered gray matter volume in the medial prefrontal cortex.^[91] 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.^[92] The results of a 2015 study associated the condition of NPD with a reduced volume of gray matter in the prefrontal cortex.^[93] The regions of the brain identified and studied – the insular cortex and the prefrontal cortex – are associated with the human emotions of empathy and compassion, and with the mental functions of cognition and emotional regulation. The neurological findings of the studies suggest that NPD may be related to a compromised capacity for emotional empathy and emotional regulation.^[94]

Evolutionary models of NPD have also been proposed.^[82] According to psychologist Marco Del Giudice, cluster B traits including NPD, predict increased mating success and fertility. NPD could potentially be an adaptive evolutionary phenomena, though a risky one that can sometimes result in social rejection and failure to reproduce.^[82] 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).^[82]

Research on NPD is limited, because patients are hard to recruit for study.^[91] The cause of narcissistic personality disorder requires further research.^[88][82]

Treatment for NPD is primarily psychotherapeutic; there is no clear evidence that psychopharmacological treatment is effective for NPD, although it can prove useful for treating comorbid disorders.^[8][95] Psychotherapeutic treatment falls into two general categories: psychoanalytic/psychodynamic and cognitive behavioral. Psychoanalytic therapies include schema therapy, transference focused psychotherapy, mentalization-based treatment and metacognitive psychotherapy. Cognitive behavioral therapies include cognitive behavioral therapy and dialectal behavior therapy. Formats also include group therapy and couples therapy.^[9] The specific choice of treatment varies based on individual presentations.^[96]

Management of narcissistic personality disorder has not been well studied, however many treatments tailored to NPD exist.^[7][1] 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.^{[97][98][99][100][101]} People with NPD often present with comorbid mental disorders, complicating diagnosis and treatment.^[1] 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.^[25]

As of 2020^[update], no treatment guidelines exist for NPD and no empirical studies have been conducted on specific NPD groups to determine efficacy for psychotherapies and pharmacology.^[7][8] 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.^[1] 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.^[102]

As of 2018^[update], overall prevalence is estimated to range from 0.8% to 6.2%.^[103][104] 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,^[105] with a 2015 study confirming the gender difference.^[106] In clinical settings, prevalence estimates range from 1% to 15%.^[6][107] The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders.^[84]

The term "narcissism" comes from a first century (written in the year 8 AD) book by the Roman poet Ovid. Metamorphoses Book III is a myth about two main characters, Narcissus and Echo. Narcissus is a handsome young man who spurns the advances of many potential lovers. When Narcissus rejects the nymph Echo, named this way because she was cursed to only echo the sounds that others made, the gods punish 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.^[108]

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:^[109]

• Havelock Ellis (1898) was the first psychologist to use the term when he linked the myth to the condition in one of his patients.^[109]
• Sigmund Freud (1905–1953) used the terms "narcissistic libido" in his Three Essays on the Theory of Sexuality.^[110][109]
• 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.

Narcissistic personality was first described by the psychoanalyst Robert Waelder in 1925.^[111] The term narcissistic personality disorder (NPD) was coined by Heinz Kohut in 1968.^[112][113] Waelder's initial study has been influential in the way narcissism and the clinical disorder Narcissistic personality disorder are defined today^[114]

Much early history of narcissism and NPD originates from psychoanalysis. Regarding the adult neurotic's sense of omnipotence, Sigmund Freud said that "this belief is a frank acknowledgement of a relic of the old megalomania of infancy";^[115] and concluded that: "we can detect an element of megalomania in most other forms of 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."^[116]

Narcissistic injury and narcissistic scar are terms used by Freud in the 1920s. Narcissistic wound and narcissistic blow are other, almost interchangeable, terms.^[117] 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;^[11] but typically, the actions and responses of the NPD person are deliberate and calculated.^[2] Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable.^[2]

In The Psychology of Gambling (1957), Edmund Bergler considered megalomania to be a normal occurrence in the psychology of a child,^[118] a condition later reactivated in adult life, if the individual takes up gambling.^[119] 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 to the megalomania of childhood.^[120]

Narcissistic supply was a concept introduced by Otto Fenichel in 1938, to describe a type of admiration, interpersonal support, or sustenance drawn by an individual from his or her environment and essential to their self-esteem.^[121] 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.^[122]

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.^[123]

Narcissistic rage reactions are not necessarily limited to narcissistic personality disorder. They may also be seen in catatonic, paranoid delusion, and depressive episodes.^[123] It was later suggested that narcissistic people have two layers of rage; the first layer of rage being directed constant anger towards someone else, with the second layer being self-deprecating.^[124]

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 Kleinian psychologists used the object relations theory to re-evaluate megalomania as a defence mechanism.^[125] 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.^[126]

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.^[127] 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.^[128]

NPD shares properties with borderline personality disorder, including social stigma, unclear causes and prevalence rates. In a 2020 study, it was argued that NPD is following a similar historical trend to borderline personality disorder: "In the past three decades, enormous progress has been made to elucidate the psychopathology, longitudinal course, and effective treatment for BPD. NPD, which remains as similarly stigmatized and poorly understood as BPD once was, now carries the potential for a new wave of investigation and treatment development."^[129]

However, NPD also shares some commonality with the now discredited "multiple personality disorder" (MPD) personality constellation in popular culture and clinical lore. MPD received a high level of mainstream media attention the 1980s, followed by a nearly complete removal from public discourse within the following two decades; this was in part due to thorough debunking many of its propositions and the evident societal harm created by its entry into the legal defence realm. Similar to MPD, NPD has been the subject of high levels of preoccupation in social and popular media forums, without a firm empirical basis despite over a century of description in clinical lore. The NPD label may be misused colloquially and clinically to disparage a target for the purpose of buttressing one's own self-esteem, or other motives that are detrimental for the person receiving the label. Finally, the rise in popular interest in NPD is not accompanied by hypothesized increases in narcissism among recent generations, despite widespread assumptions to the contrary.^[130]

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 Gunderson, who led the DSM personality disorders committee for the 4th edition of the manual.^[131]

The American Psychiatric Association's (APA) formulation, description, and definition of narcissistic personality disorder, as published in the 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.^[46]

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.^[132][133] 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.^[134] 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.

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.^[135] 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."^[136] 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.^[137]

• 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".^[138]
• 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 high society", has been described by English professor Giles Mitchell as a "pathological narcissist" for whom the "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.^[139][140]

• Messiah complex
• Superiority complex