Narcissistic personality disorder

Short description: 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]
Personality disorders

Cluster A (odd)

* Paranoid
* Schizoid
* Schizotypal

Cluster B (dramatic)

* Antisocial
* Borderline
* Histrionic
* Narcissistic

Cluster C (anxious)

* Avoidant
* Dependent
* Obsessive–compulsive

Not specified

* Depressive
* Haltlose
* Passive–aggressive
* Sadistic
* Self-defeating
* Psychopathic

* v
* t
* e

Narcissistic personality disorder (NPD) is a complex and heterogeneous personality disorder characterized by patterns of grandiosity, entitlement, low empathy, and interpersonal difficulties, which can manifest as either grandiose (“thick-skinned”) or vulnerable (“thin-skinned”) forms.[1][2] Grandiose individuals display arrogance, social dominance, and exploitative behaviors, while vulnerable individuals show shame, inferiority, hypersensitivity, and extreme reactions to criticism. NPD often involves impaired emotional empathy, superficial relationships, and difficulty tolerating disagreement. It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability.[1]

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 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.[5][6] Its high comorbidity with other mental disorders influences treatment and outcomes.[5] Psychotherapeutic treatments generally fall into two categories: psychoanalytic/psychodynamic and cognitive behavioral therapy, with growing support for integration of both in therapy.[7][8] However, there are few studies on the effectiveness of treatments.[6] 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.[9]

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.

## Contents

* 1 Signs and symptoms
* 1.1 Other features
* 2 Causes
* 2.1 Aetiology
* 2.2 Pathophysiology
* 2.3 Other aspects
* 3 Diagnosis
* 3.1 Classification
* 3.1.1 DSM-5
* 3.1.2 ICD-11
* 3.2 Differential diagnosis and comorbitity
* 4 Subtypes
* 4.1 Empirically verified subtypes
* 4.2 Others
* 4.2.1 Millon's subtypes
* 4.2.2 Masterson's subtypes (exhibitionist and closet)
* 4.2.3 Malignant narcissism
* 4.2.4 Historical demarcation of grandiose and vulnerable types
* 5 Assessment and screening
* 5.1 Narcissistic Personality Inventory
* 5.2 Pathological Narcissism Inventory
* 5.3 Five-Factor Narcissism Inventory
* 5.4 Millon Clinical Multiaxial Inventory
* 6 Management
* 7 Prognosis
* 8 Epidemiology
* 9 History
* 9.1 Freudianism and psychoanalysis
* 9.1.1 Narcissistic supply
* 9.1.2 Narcissistic rage
* 9.2 Object relations
* 9.3 Modern diagnosis
* 10 Controversy
* 11 In popular culture
* 12 See also
* 13 References
* 14 Further reading
* 15 External links

## Signs and symptoms

> 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.[10]

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.[10]

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 characterised 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.[11]

While vulnerable-type patients typically show extreme distress and dysfunction, grandiose variants tend to be associated with greater psychological wellbeing,[12][13] often manifesting dysfunction by occupational conflict, harming others, antisocial behaviour or emotional strain resulting from perfectionism.[10][12][14][15]

It is often theorised that some patients may oscillate between grandiosity and vulnerability.[16] While some evidence suggests that grandiose individuals show occasional reactive anger (a vulnerable trait), but narcissistically vulnerable individuals do not show signs of grandiosity,[16][17] most studies show the vulnerable individuals show occasional bouts of grandiosity, narcissistically grandiose individuals show few or no signs of vulnerability.[18][19][20][21]

### Other features

NPD patients may have difficulty accepting help.[22] They may also exhibit vengeful fantasies,[23][24] as well as violent and antisocial behaviour.[25][15] They are more likely to try forms of plastic surgery due to a desire to gain attention and to be seen as beautiful.[26][27]

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[28][29] but preserved capacity for cognitive empathy or an impaired theory of mind.[30] People with NPD are less likely to engage in prosocial behavior.[31] They can still act in selfless ways to improve others' perceptions of them, advance their social status, or if explicitly told to.[32] Despite these characteristics, they are more likely to overestimate their capacity for empathy.[33] Recent work, however, suggests narcissistic empathy deficits may be resolved (at least in part) by instructed perspective-taking.[34]

It is common for people with NPD to have difficult relationships.[35][36][37][38] They may disrespect others' boundaries or idealize and devalue them. They commonly keep people emotionally distant, and project, deny,[39] or split. NPD individuals manifesting vulnerability tend to become enraged when rejected or criticised,[35][40][41] and may degrade, insult, or blame others who disagree with them.[42][43]

NPD may be associated with reduced insight into symptoms, especially in severe cases.[44] 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.[45] 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][27] 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]

## Causes

### Aetiology

The cause of narcissistic personality disorder (NPD) is unclear, although there is evidence for a strong biological or genetic underpinning.[48][49][50][51] It is unclear if or how much a person's upbringing contributes to the development of NPD, although many speculative theories have been proposed.[48][52][53][54]

Evidence to support social factors in the development of NPD is limited.[48][54] Some studies have found NPD correlates with permissive and overindulgent parenting in childhood, while others have found correlations with harsh discipline, neglect or abuse.[48] Findings have been inconsistent, and scientists do not know if these correlations are causal, as these studies do not control for genetic confounding.[48][54]

This problem of genetic confounding is explained by psychologist Svenn Torgersen in a 2009 review:[54]

> 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.[54]

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).[55][56][54] 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:[49]

> 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[49]

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.[56]

### Pathophysiology

Neuroscientists have also studied the brains of people with NPD using structural imaging technology.[57] 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.[57] 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.[58] The results of a 2015 study associated the condition of NPD with a reduced volume of gray matter in the prefrontal cortex.[59] 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.[60] 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.[61]

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.[62] Vulnerable cases of NPD also appear to show increased oxidative stress.[63]

### Other aspects

Evolutionary models of NPD have also been proposed.[48] 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.[48] 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).[48]

Research on NPD is limited, because patients are hard to recruit for study.[57] The cause of narcissistic personality disorder requires further research.[54][48]

## 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.

### 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. While personality disorders, including NPD, are diagnosed as separate entities in the DSM-5; in the ICD-11 classification of personality disorders, they are assessed in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology.[64] There is also a hybrid model,[65] called the Alternative DSM-5 model for personality disorders, which defines NPD and five other PDs through disorder-specific combinations of pathological traits and areas of overall impairment.[64]

#### DSM-5

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), there are two frameworks for personality disorders,[64] with the categorical framework of previous editions having been retained as the main model,[66] and criteria remaining the same as in the DSM-IV-TR.[67] The categorical framework contains ten specific personality disorder categories, grouped into three clusters, with NPD belonging to cluster B, the disorders belonging to which often appear dramatic, emotional, or erratic.[2] NPD is defined by a subject meeting at least five of nine specified criteria.[2] 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.[68]

Having initially been developed as a replacement for the categorical model, the Alternative DSM-5 Model for Personality Disorders (AMPD) is located in Section III of both the DSM-5 and DSM-5-TR due to the replacement having been rejected.[69] The AMPD defines six specific personality disorders – one of them being NPD[70] – in terms of a description of the disorder; the characteristic manner in which the disorder impacts personality functioning, i.e. identity, self-direction, empathy and intimacy (criterion A); as well as a listing and description of the pathological personality traits associated with the disorder (criterion B).[71]

General personality impairment in individuals with NPD, as described in the AMPD, involves a fragile or exaggerated self-image that depends on others' approval, leading to unstable self-esteem. Their personal goals are often shaped by a need for recognition, with standards that are either unrealistically high or based on entitlement. They struggle to recognize others’ feelings unless directly relevant to themselves and often misjudge their own impact on others. Relationships are typically superficial, serving self-enhancement rather than mutual connection. At least two of these elements must have a "moderate or greater impairment".[72]

The AMPD lists the following pathological traits, both of which are required: grandiosity and attention-seeking; each of these is followed by a description of how the trait manifests in NPD. The AMPD specifiers allow for additional traits to be specified; it suggests additional antagonistic traits for "malignant", and traits of negative affectivity for "vulnerable" manifestations of NPD.[72] Further requirements beyond traits and severity, for example relating to differential diagnosis, are embodied in criteria C–G.[65]

#### ICD-11

The World Health Organization's ICD-11 has replaced the categorical classification of personality disorders in the ICD-10 with a dimensional model containing a unified personality disorder (6D10) with severity specifiers, along with specifiers for prominent personality traits or patterns (6D11).[73] 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,[74] while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.[75]

Studies have shown that NPD corresponds well to the ICD-11 trait of Dissociality (6D11.2)[76][75] – especially self-centredness[75] (grandiosity, attention-seeking, entitlement and egocentricity; Dissociality also includes lack of empathy[73]), 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."[75] Vulnerable features are associated with Negative Affectivity (6D11.0),[76] 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."[75]

An ICD-11 case profile of a presentation aligning with anankastic and other specific (narcissistic) PD diagnoses in the ICD-10 could look like this.[73]

NPD also shows secondary links to Anankastia (6D11.4) and Disinhibition (6D11.3).[76] The connection to Anankastia may reflect perfectionistic traits that support grandiosity and competitiveness,[76][75] while the link to Disinhibition may involve impulsivity, overconfidence, and difficulty with long-term planning.[76] The complex and variable trait profile across ICD-11 domains reflects the diverse presentations of narcissism.[76] The involvement of multiple domains supports the traditional view that narcissistic pathology entails moderate to severe impairments in personality functioning.[76]

### Differential diagnosis and comorbitity

NPD may be comorbid or differentiated with the occurrence of other mental disorders.[2] 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).[77] Another PD comorbidity is paranoid personality disorder.[2]

Borderline PD is characterized as having an instability in emotions, relationships, and self image.[78] 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 does, in fact, have high comorbidity rates with NPD.[79] 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.[80] Additionally, both antisociality and narcissism are heavily correlated with psychopathy, further suggesting an overlap between the two.[81]

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.[82]

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."[2] The person's manifested personality traits must substantially differ from social norms.[2]

## 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.[1][83][84] 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.[7][83] 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,[85] 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.[86] This group was noted for high levels of comorbid antisocial and paranoid personality disorders, substance abuse, externalizing, unemployment and greater likelihood of violence.[85][87] 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.[87]

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.[88] Vulnerable narcissism is sometimes comorbid with diagnoses of avoidant, borderline and dependent personality disorders.[85][87]

High-functioning/exhibitionistic: A third subtype for classifying people with NPD, initially theorized by psychiatrist Glen Gabbard, is termed high functioning or exhibitionistic.[89][85] 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."[83] 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.[85]

### Others

Oblivious/hypervigilant: Glen Gabbard described two subtypes of NPD in 1989, later referred to as equivalent to, the grandiose and vulnerable subtypes.[90][91][89] 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.[92][93] 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.[94]

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, often with exotic partners.[citation needed]
Compensatory narcissist | Seeks to counteract or cancel out deep feelings of inferiority and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, noteworthy; self-worth results from self-enhancement.
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.[95] 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.[96]

#### Malignant narcissism

Main article: Philosophy:Malignant narcissism

Malignant narcissism, a term first coined in Erich Fromm's 1964 book The Heart of Man: Its Genius for Good and Evil,[97] 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.[98]

#### 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:[99]

| 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 article: Philosophy:Narcissistic Personality Inventory

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.[100]

### 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.[100][101]

The PNI scales show significant associations with parasuicidal behavior, suicide attempts, homicidal ideation, and several aspects of psychotherapy utilization.[102]

### 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).[103] Later analysis revealed that the FFNI actually measures three factors:[104]

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 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.[104][105]

### Millon Clinical Multiaxial Inventory

Main article: Social: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.[106] 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.[107]

A 2020 study found that females scored significantly higher on vulnerable narcissism than males, but no gender differences were found for grandiose narcissism.[108]

## Management

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.[7][109] 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.[8] The specific choice of treatment varies based on individual presentations.[110]

Management of narcissistic personality disorder has not been well studied, however many treatments tailored to NPD exist.[6][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.[111][112][113][114][115] 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.[27]

## Prognosis

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.[6][7] 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.[116]

## Epidemiology

As of 2018[update], overall prevalence is estimated to range from 0.8% to 6.2%.[117][118] 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,[119] with a 2015 study confirming the gender difference.[120] In clinical settings, prevalence estimates range from 1% to 15%.[5][121]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.[119]

The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders.[50][122] 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.[123] NPD is associated with the occurrence of bipolar disorder and substance use disorders,[1][27] especially cocaine use disorder.[2]

## History

The term "narcissism" comes from the first century (written in the year 8 AD) narrative poem the Metamorphoses by the Roman poet Ovid. Book III of the Metamorphoses features 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 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.[124]

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:[125]

* Havelock Ellis (1898) was the first psychologist to use the term when he linked the myth to the condition in one of his patients.[125]
* Sigmund Freud (1905–1953) used the terms "narcissistic libido" in his Three Essays on the Theory of Sexuality.[126][125]
* 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.[127] The term narcissistic personality disorder (NPD) was coined by Heinz Kohut in 1968.[128][129] Waelder's initial study has been influential in the way narcissism and the clinical disorder Narcissistic personality disorder are defined today[130]

### Freudianism and psychoanalysis

Much of the 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";[131] 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."[132]

Narcissistic injury and narcissistic scar are terms used by Freud in the 1920s. Narcissistic wound and narcissistic blow are other, almost interchangeable, terms.[133] 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;[82] 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,[134] a condition later reactivated in adult life, if the individual takes up gambling.[135] 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.[136]

#### Narcissistic supply

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.[137] 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.[138]

#### 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.[139]

Narcissistic rage reactions are not necessarily limited to narcissistic personality disorder. They may also be seen in catatonic, paranoid delusion, and depressive episodes.[139]

### 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 Kleinian psychologists used the object relations theory to re-evaluate megalomania as a defence mechanism.[140] 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.[140]

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.[141] 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.[142]

### 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 (F60.8),[143] 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.[144][original research?]

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.[145]

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.[146][147] 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.[148] 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.[149] 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."[150]

## In popular culture

* 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".[151]
* 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.[152][153]

## See also

* Identity disturbance
* Messiah complex
* Narcissistic neurosis
* Superiority complex
* True self and false self

## References

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2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 Diagnostic and statistical manual of mental disorders : DSM-5. (5th ed.). Arlington, Virginia: American Psychiatric Association. 2013. pp. 72–669. ISBN 978-0-89042-554-1. OCLC 830807378.
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47. ↑ Trapped in the Mirror: Adult Children of Narcissists in Their Struggle For Self (1st ed.). New York: W. W. Morrow. 1992. ISBN 0-688-09471-6. OCLC 23143624.
48. ↑ 48.0 48.1 48.2 48.3 48.4 48.5 48.6 48.7 48.8 Del Giudice, Marco (2018), Del Giudice, Marco, ed., "Personality Disorders" (in en), Evolutionary Psychopathology (Oxford University Press): pp. 272–284, doi:10.1093/med-psych/9780190246846.003.0012, ISBN 978-0-19-024684-6, https://academic.oup.com/book/1052/chapter/138276725
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60. ↑ 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.
61. ↑ 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.
62. ↑ 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.
63. ↑ Lee, RJ; Gozal, D; Coccaro, EF; Fanning, J (March 2020). "Narcissistic and Borderline Personality Disorders: Relationship With Oxidative Stress.". Journal of Personality Disorders 34 (Suppl): 6–24. doi:10.1521/pedi.2020.34.supp.6. PMID 32186978.
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65. ↑ 65.0 65.1 Rodriguez-Seijas, Craig; Ruggero, Camilo; Eaton, Nicholas R.; Krueger, Robert F. (2019). "The DSM-5 Alternative Model for Personality Disorders and Clinical Treatment: a Review" (in en). Current Treatment Options in Psychiatry 6 (4): 284–298. doi:10.1007/s40501-019-00187-7. ISSN 2196-3061. https://link.springer.com/10.1007/s40501-019-00187-7.
66. ↑ Strickland, Casey M.; Hopwood, Christopher J.; Bornovalova, Marina A.; Rojas, Elizabeth C.; Krueger, Robert F.; Patrick, Christopher J. (April 2019). "Categorical and Dimensional Conceptions of Personality Pathology in DSM-5: Toward a Model-Based Synthesis". Journal of Personality Disorders 33 (2): 185–213. doi:10.1521/pedi_2018_32_339. ISSN 0885-579X. PMID 29505383. https://doi.org/10.1521/pedi_2018_32_339.
67. ↑ Trestman, Robert L. (2014). "DSM-5 and personality disorders: where did axis II go?". The Journal of the American Academy of Psychiatry and the Law 42 (2): 141–145. ISSN 1943-3662. PMID 24986340. "The APA Board of Trustees ultimately decided to keep all 10 personality disorders from DSM-IV-TR unchanged (with only minor text updating).".
68. ↑ "Narcissist or narcissistic? Evaluation of the latent structure of narcissistic personality disorder". Journal of Abnormal Psychology 127 (5): 496–502. July 2018. doi:10.31234/osf.io/tv7r9. PMID 30010367.
69. ↑ Sharp, Carla; Clark, Lee Anna; Balzen, Kennedy M.; Widiger, Tom; Stepp, Stephanie; Zimmerman, Mark; Krueger, Robert F. (2025). "The validity, reliability and clinical utility of the Alternative DSM ‐5 Model for Personality Disorders ( AMPD ) according to DSM ‐5 revision criteria" (in en). World Psychiatry 24 (3): 319–340. doi:10.1002/wps.21339. ISSN 1723-8617. PMID 40948060. PMC 12434376. https://onlinelibrary.wiley.com/doi/10.1002/wps.21339.
70. ↑ Christopher Fowler, J.; Sharp, Carla; Kalpakci, Allison; Madan, Alok; Clapp, Joshua; Allen, Jon G.; Christopher Frueh, B.; Oldham, John M. (2015-01-01). "A dimensional approach to assessing personality functioning: examining personality trait domains utilizing DSM-IV personality disorder criteria". Comprehensive Psychiatry 56: 75–84. doi:10.1016/j.comppsych.2014.09.001. ISSN 0010-440X. PMID 25261890. https://www.sciencedirect.com/science/article/pii/S0010440X14002521. "The number of specific PDs was reduced from 10 to 6 (antisocial, avoidant, borderline, narcissistic, obsessive–compulsive, and schizotypal) as well as a diagnosis of "personality disorder—trait specified" that can be made when criteria for a specific disorder are not met, but a personality disorder is assessed as present [23].".
71. ↑ Zimmermann, Johannes; Kerber, André; Rek, Katharina; Hopwood, Christopher J.; Krueger, Robert F. (2019-08-13). "A Brief but Comprehensive Review of Research on the Alternative DSM-5 Model for Personality Disorders" (in en). Current Psychiatry Reports 21 (9): 92. doi:10.1007/s11920-019-1079-z. ISSN 1535-1645. https://doi.org/10.1007/s11920-019-1079-z.
72. ↑ 72.0 72.1 American Psychiatric Association, ed (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, D.C: American Psychiatric Association. pp. 767–768. ISBN 978-0-89042-554-1.
73. ↑ 73.0 73.1 73.2 "Application of the ICD-11 classification of personality disorders". BMC Psychiatry 18 (1). October 2018. doi:10.1186/s12888-018-1908-3. PMID 30373564.
74. ↑ Swales, Michaela A. (2022-12-15). "Personality Disorder Diagnoses in ICD-11: Transforming Conceptualisations and Practice" (in en). Clinical Psychology in Europe 4 (Spec Issue). doi:10.32872/cpe.9635. ISSN 2625-3410. PMID 36760321. PMC 9881116. https://cpe.psychopen.eu/index.php/cpe/article/view/9635.
75. ↑ 75.0 75.1 75.2 75.3 75.4 75.5 Bach, Bo; Kramer, Ueli; Doering, Stephan; di Giacomo, Ester; Hutsebaut, Joost; Kaera, Andres; De Panfilis, Chiara; Schmahl, Christian et al. (2022-04-01). "The ICD-11 classification of personality disorders: a European perspective on challenges and opportunities". Borderline Personality Disorder and Emotion Dysregulation 9 (1): 12. doi:10.1186/s40479-022-00182-0. ISSN 2051-6673. PMID 35361271.
76. ↑ 76.0 76.1 76.2 76.3 76.4 76.5 76.6 Simon, Jonatan; Lambrecht, Bastian; Bach, Bo (2023-04-06). "Cross-walking personality disorder types to ICD-11 trait domains: An overview of current findings" (in English). Frontiers in Psychiatry 14. doi:10.3389/fpsyt.2023.1175425. ISSN 1664-0640. PMID 37091704.
77. ↑ "APA Dictionary of Psychology" (in en). https://dictionary.apa.org/personality-disorder.
78. ↑ Douk, K; Belabess, I; Hanine, I (2023). "Comorbidity borderline-narcissistic personality disorder". European Psychiatry 66 (Suppl 1): S364. doi:10.1192/j.eurpsy.2023.790.
79. ↑ Bornstein, Robert F.; Gold, Stephanie H. (2008-06-01). "Comorbidity of Personality Disorders and Somatization Disorder: A Meta-analytic Review" (in en). Journal of Psychopathology and Behavioral Assessment 30 (2): 154–161. doi:10.1007/s10862-007-9052-2. ISSN 1573-3505. https://link.springer.com/article/10.1007/s10862-007-9052-2.
80. ↑ "Antisocial Personality Disorder: Often Overlooked and Untreated" (in en). https://www.psychiatry.org/news-room/apa-blogs/antisocial-personality-disorder-often-overlooked#:~:text=People with antisocial personality disorder,show no remorse or guilt..
81. ↑ Sylvers, Patrick; Brubaker, Nicholas; Alden, S. Amanda; Brennan, Patricia A.; Lilienfeld, Scott O. (2008-10-01). "Differential endophenotypic markers of narcissistic and antisocial personality features: A psychophysiological investigation". Journal of Research in Personality 42 (5): 1260–1270. doi:10.1016/j.jrp.2008.03.010. ISSN 0092-6566. https://www.sciencedirect.com/science/article/abs/pii/S0092656608000494.
82. ↑ 82.0 82.1 "Narcissistic personality disorder – Symptoms & causes". Phoenix, Arizona: Mayo Foundation for Medical Education and Research. 18 November 2017. https://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/symptoms-causes/syc-20366662.
83. ↑ 83.0 83.1 83.2 "Subtypes, dimensions, levels, and mental states in narcissism and narcissistic personality disorder". Journal of Clinical Psychology 68 (8): 886–897. August 2012. doi:10.1002/jclp.21893. PMID 22740389.
84. ↑ "In Search of Narcissus". Trends in Cognitive Sciences 25 (1): 67–80. January 2021. doi:10.1016/j.tics.2020.10.010. PMID 33229145. https://eprints.soton.ac.uk/445148/1/In_search_of_narcissus.docx.
85. ↑ 85.0 85.1 85.2 85.3 85.4 "Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes". The American Journal of Psychiatry 165 (11): 1473–1481. November 2008. doi:10.1176/appi.ajp.2008.07030376. PMID 18708489.
86. ↑ "Grandiose and vulnerable narcissism: a nomological network analysis". Journal of Personality (Wiley) 79 (5): 1013–1042. October 2011. doi:10.1111/j.1467-6494.2010.00711.x. PMID 21204843.
87. ↑ 87.0 87.1 87.2 "Clinician Emotional Responses and Therapeutic Alliance When Treating Adolescent Patients With Narcissistic Personality Disorder Subtypes: A Clinically Meaningful Empirical Investigation". Journal of Personality Disorders 34 (Suppl): 42–62. March 2020. doi:10.1521/pedi.2020.34.supp.42. PMID 32186983.
88. ↑ Miller, Joshua D.; Lynam, Donald R.; Vize, Colin; Crowe, Michael; Sleep, Chelsea; Maples-Keller, Jessica L.; Few, Lauren R.; Campbell, W. Keith (April 2018). "Vulnerable Narcissism Is (Mostly) a Disorder of Neuroticism" (in en). Journal of Personality 86 (2): 186–199. doi:10.1111/jopy.12303. ISSN 0022-3506. PMID 28170100. https://onlinelibrary.wiley.com/doi/10.1111/jopy.12303.
89. ↑ 89.0 89.1 "Narcissism and suicide risk". Annals of General Psychiatry (BioMed Central Ltd.) 21 (1). January 2022. doi:10.1186/s12991-022-00380-8. PMID 35065658.
90. ↑ "Two subtypes of narcissistic personality disorder". Bulletin of the Menninger Clinic 53 (6): 527–532. 1989. PMID 2819295.
91. ↑ "Transference and Countertransference: Developments in the Treatment of Narcissistic Personality Disorder". Psychiatric Annals (Thorofare, New Jersey: SLACK Incorporated) 39 (3): 129–136. March 2009. doi:10.3928/00485713-20090301-03. ISSN 0048-5713.
92. ↑ "Communal narcissism". Journal of Personality and Social Psychology 103 (5): 854–878. November 2012. doi:10.1037/a0029629. PMID 22889074.
93. ↑ "Know the Kind of Narcissist You're Dealing With and Symptoms". PsychologyToday.com. 6 March 2021. https://www.psychologytoday.com/us/blog/toxic-relationships/202103/know-the-kind-narcissist-youre-dealing-and-symptoms.
94. ↑ Disorders of Personality: DSM-IV and Beyond. New York City: John Wiley & Sons, Inc.. 1996. p. 226. ISBN 978-0-471-01186-6.
95. ↑ The Emerging Self: A Developmental Self & Object Relations Approach to the Treatment of the Closet Narcissistic Disorder of the Self. Hove, Sussex, England: Psychology Press. 1993. p. 4. ISBN 978-1-315-82578-6.
96. ↑ "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". Borderline Personality Disorder and Emotion Dysregulation (BioMed Central) 3 (14). October 13, 2016. doi:10.1186/s40479-016-0046-0. PMID 27777779.
97. ↑ The Heart of Man: Its Genius for Good and Evil. San Francisco: Harper & Row. 1964. p. 92. ISBN 978-9933-432-30-0.
98. ↑ "Malignant Narcissism in Relation to Clinical Change in Borderline Personality Disorder: An Exploratory Study". Psychopathology 51 (5): 318–325. 2018. doi:10.1159/000492228. PMID 30184541.
99. ↑ "Narcissistic Grandiosity and Narcissistic Vulnerability". The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments. John Wiley & Sons, Inc.. 2011. pp. 31–40. doi:10.1002/9781118093108.ch4. ISBN 978-1-118-09310-8.
100. ↑ 100.0 100.1 "Measures of Narcissism and Their Relations to DSM-5 Pathological Traits: A Critical Reappraisal". Assessment 23 (1): 3–9. February 2016. doi:10.1177/1073191114522909. PMID 24550548.
101. ↑ "Rejoinder: A Construct Validity Approach to the Assessment of Narcissism". Assessment 23 (1): 18–22. February 2016. doi:10.1177/1073191115608943. PMID 26463683.
102. ↑ "Initial construction and validation of the Pathological Narcissism Inventory". Psychological Assessment (American Psychological Association) 21 (3): 365–379. September 2009. doi:10.1037/a0016530. PMID 19719348.
103. ↑ "The Five-Factor Narcissism Inventory (FFNI): a test of the convergent, discriminant, and incremental validity of FFNI scores in clinical and community samples". Psychological Assessment 25 (3): 748–758. September 2013. doi:10.1037/a0032536. PMID 23647044.
104. ↑ 104.0 104.1 "Clinical Correlates of Vulnerable and Grandiose Narcissism: A Personality Perspective". Journal of Personality Disorders 34 (1): 107–130. February 2020. doi:10.1521/pedi_2018_32_384. PMID 30179576.
105. ↑ "The relation between narcissism and aggression: A meta-analysis". Journal of Personality 90 (4): 574–594. August 2022. doi:10.1111/jopy.12684. PMID 34689345.
106. ↑ "Validation of two scales for narcissistic personality disorder". Journal of Personality Assessment (Taylor & Francis) 48 (6): 649–653. December 1984. doi:10.1207/s15327752jpa4806_13. PMID 6520692.
107. ↑ "Are there such things as 'Narcissists'? A taxometric analysis of the Narcissistic Personality Inventory". Personality and Individual Differences (Amsterdam, Netherlands: Elsevier) 43 (6). October 2007. doi:10.1016/j.paid.2007.04.003.
108. ↑ "Recollections of parenting styles in the development of narcissism: The role of gender" (in en). Personality and Individual Differences (Amsterdam, Netherlands: Elsevier) 167. December 1, 2020. doi:10.1016/j.paid.2020.110246. ISSN 0191-8869. https://napier-surface.worktribe.com/2676428/1/Recollections Of Parenting Styles In The Development Of Narcissism: The Role Of Gender (accepted version).
109. ↑ "Narcissistic personality disorder – Diagnosis and treatment". 18 November 2017. https://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/diagnosis-treatment/drc-20366690.
110. ↑ "Motive-Oriented Psychotherapeutic Relationship Facing a Patient Presenting with Narcissistic Personality Disorder: A Case Study". Journal of Contemporary Psychotherapy 44 (2): 71–82. June 2014. doi:10.1007/s10879-013-9249-5. https://boris.unibe.ch/65606/.
111. ↑ "Further assessment of the construct validity of four measures of narcissism: replication and extension". The Journal of Psychology 135 (3): 245–258. May 2001. doi:10.1080/00223980109603695. PMID 11577967.
112. ↑ "Expanding the Nomological Net of the Pathological Narcissism Inventory: German Validation and Extension in a Clinical Inpatient Sample". Assessment 24 (4): 419–443. June 2017. doi:10.1177/1073191115627010. PMID 26874362.
113. ↑ "The Dark Triad, happiness and subjective well-being" (in en). Personality and Individual Differences 67: 17–22. September 2014. doi:10.1016/j.paid.2014.01.004. https://pureadmin.qub.ac.uk/ws/files/219337558/Wellbeing.pdf.
114. ↑ "The burden of disease in personality disorders: diagnosis-specific quality of life". Journal of Personality Disorders 22 (3): 259–268. June 2008. doi:10.1521/pedi.2008.22.3.259. PMID 18540798.
115. ↑ "Narcissism and Quality of Life: The Mediating Role of Relationship Patterns". The Journal of Nervous and Mental Disease 208 (8): 613–618. August 2020. doi:10.1097/NMD.0000000000001170. PMID 32229790.
116. ↑ "Can Narcissists Change?". 17 December 2017. https://psychcentral.com/disorders/narcissistic-personality-disorder/treatment.
117. ↑ "Prevalence, Mortality, and Health Care Use among Patients with Cluster B Personality Disorders Clinically Diagnosed in Quebec: A Provincial Cohort Study, 2001-2012". Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 62 (5): 336–342. May 2017. doi:10.1177/0706743717700818. PMID 28403655.
118. ↑ "Prevalence and treatment of narcissistic personality disorder in the community: a systematic review". Comprehensive Psychiatry 51 (4): 333–339. July–August 2010. doi:10.1016/j.comppsych.2009.09.003. PMID 20579503.
119. ↑ 119.0 119.1 "Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions". The Journal of Clinical Psychiatry 69 (7): 1033–1045. July 2008. doi:10.4088/jcp.v69n0701. PMID 18557663.
120. ↑ "Gender differences in narcissism: a meta-analytic review". Psychological Bulletin 141 (2): 261–310. March 2015. doi:10.1037/a0038231. PMID 25546498. http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1004&context=pdharms.
121. ↑ "Chapter 4: Personality Disorders". Blueprints Psychiatry (5th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. 2009. p. 29. ISBN 978-0-7817-8253-1. https://books.google.com/books?id=7_7-5dQIpBQC&pg=PA29.
122. ↑ "Modernity and narcissistic personality disorder". Personality Disorders 5 (2): 220–226. April 2014. doi:10.1037/a0028580. PMID 22800179.
123. ↑ Narcissistic personality disorder, U.S. National Library of Medicine, 8 July 2018, https://medlineplus.gov/ency/article/000934.htm
124. ↑ "Narcissus Greek mythology". Britanica. https://www.britannica.com/topic/Narcissus-Greek-mythology.
125. ↑ 125.0 125.1 125.2 Personality Disorders in Modern Life. Wiley. 2004. p. 343. ISBN 978-0-471-23734-1. http://leipper.org/manuals/zip-fill/Personality Disorders in Modern Life 2ND ED - THEODORE MILLON.pdf.
126. ↑ Freud: On Narcissism, University of Hawaii, 1998, http://www.english.hawaii.edu/criticalink/narc/guide1.html .
127. ↑ "The psychoses: Their mechanisms and accessibility to influence". International Journal of Psycho-Analysis 6: 259–281. 1925.
128. ↑ Personality disorders : toward the DSM-V. Los Angeles: Sage Publications. 2007. p. 235. ISBN 978-1-4129-0422-3. OCLC 77716529.
129. ↑ "The psychoanalytic treatment of narcissisticppersonality disorders. Outline of a systematic approach". The Psychoanalytic Study of the Child (Taylor & Francis) 23: 86–113. 1968. doi:10.1080/00797308.1968.11822951. PMID 5759031.
130. ↑ Anatomy of Loving; Man's Quest to Know what Love I. Ballantine Books. 1987. ISBN 978-0-449-90553-1.
131. ↑ (in English) Case Histories II. London, England: Penguin Books. 1990. pp. 113. ISBN 978-0-14-013799-6. OCLC 490712192.
132. ↑ Freud, p. 203.
133. ↑ Comprehensive Dictionary of Psychoanalysis. Abingdon, England: Routledge. 2018. p. 182. ISBN 978-1-85575-471-3.
134. ↑ The Psychology of Gambling. London: International Universities Press. 1974. pp. 176, 182. ISBN 978-1-111-91633-6.
135. ↑ "The Psychodynamics of Gambling". The Annals of the American Academy of Political and Social Science 269 (1): 93–107. May 1950. doi:10.1177/000271625026900114.
136. ↑ (in English) Psychoanalytic Theory of Neurosis. Abingdon, England: Taylor & Francis. 2016. pp. 420. ISBN 978-1-138-14782-9. OCLC 960836519.
137. ↑ "The Drive to Amass Wealth". The Psychoanalytic Quarterly 7 (1): 69–95. 1938. doi:10.1080/21674086.1938.11925342. http://freudians.org/wp-content/uploads/2014/09/Fenichel-The-Drive-to-Amass-Wealth.pdf. Retrieved 16 September 2021.
138. ↑ "StackPath". https://www.healthyplace.com/personality-disorders/malignant-self-love/narcissists-narcissistic-supply-and-sources-of-supply. [unreliable source?]
139. ↑ 139.0 139.1 Homicide: A Psychiatric Perspective. Washington, D.C.: American Psychiatric Association. 2006. pp. 181–82. ISBN 978-1-58562-204-7.
140. ↑ 140.0 140.1 (in English) From obstacle to ally: the evolution of psychoanalytic practice. New York: Brunner-Routledge. 2004. pp. 175. ISBN 978-1-58391-890-6. OCLC 57488252.
141. ↑ "The effect of pathological narcissism on interpersonal and affective processes in social interactions". Journal of Abnormal Psychology 126 (7): 898–910. October 2017. doi:10.1037/abn0000286. PMID 29106275.
142. ↑ "Dyadic splitting in partner relational disorders". Journal of Family Psychology 20 (3): 418–422. September 2006. doi:10.1037/0893-3200.20.3.418. PMID 16937998.
143. ↑ Day, Nicholas J. S.; Green, Ava; Denmeade, Georgia; Bach, Bo; Grenyer, Brin F. S. (August 2024). "Narcissistic personality disorder in the ICD-11: Severity and trait profiles of grandiosity and vulnerability" (in en). Journal of Clinical Psychology 80 (8): 1917–1936. doi:10.1002/jclp.23701. ISSN 0021-9762. PMID 38742471. "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).".
144. ↑ WHO (2010) ICD-10: Specific Personality Disorders
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## Further reading

* Narcissism : denial of the true self. New York: Simon & Schuster. 1997. ISBN 978-0-7432-5543-1.
* Rethinking narcissism: the bad-and surprising good-about feeling special. New York: Harper Wave. 2015. ISBN 978-0-06-234810-4.
* The Narcissistic and Borderline Disorders: An Integrated Developmental Approach. London: Routledge. 1981. doi:10.4324/9780203776148. ISBN 978-0-87630-292-7.
* Essential papers on narcissism. Essential Papers in Psychoanalysis. 13. New York: New York University Press. 1986. ISBN 978-0-8147-5395-8.
* Shame: The Underside of Narcissism. New York: Analytic Press. 1989. ISBN 978-1-317-77161-6.
* Maintaining relationships through communication : relational, contextual, and cultural variations. Mahwah, NJ: Lawrence Erlbaum Associates. 2003. ISBN 978-0-8058-3990-6.
* Narcissism: Behind the Mask. Sussex: Book Guild. 2010. ISBN 978-1-84624-506-0.

## External links

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* Alternative DSM-5 Model for Personality Disorders (with AMPD definition of NPD)

Classification|

* ICD-10: F60.8
* ICD-9-CM: 301.81
* MeSH: D010554

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External resources|

* MedlinePlus: 000934

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ICD-10 personality disorders

Schizotypal|

* Schizotypal

Specific|

* Anankastic
* Anxious (avoidant)
* Dependent
* Dissocial
* Emotionally unstable
* Histrionic
* Paranoid
* Schizoid

Other|

* Eccentric
* Haltlose type
* Immature
* Narcissistic
* Passive–aggressive
* Psychoneurotic

Organic|

* Organic

Unspecified|

* Unspecified

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Narcissism

Types|

* Collective
* Egomania
* Flying monkeys
* Healthy
* Malignant
* Narcissistic personality disorder
* Spiritual
* Workplace

Characteristics|

* Betrayal
* Boasting
* Egocentrism
* Egotism
* Empathy (lack of)
* Envy
* Entitlement (exaggerated sense of)
* Fantasy
* Grandiosity
* Hubris
* Magical thinking
* Manipulative
* Narcissistic abuse
* Narcissistic elation
* Narcissistic rage and narcissistic injury
* Narcissistic mortification
* Narcissistic supply
* Narcissistic withdrawal
* Perfectionism
* Self-esteem
* Self-righteousness
* Shamelessness
* Superficial charm
* Superiority complex
* True self and false self
* Vanity

Defences|

* Denial
* Idealization and devaluation
* Distortion
* Projection
* Splitting

Cultural phenomena|

* Control freak
* Don Juanism
* Dorian Gray syndrome
* My way or the highway
* Selfie

Related articles|

* Codependency
* Counterdependency
* Dark triad
* Ego ideal
* "Egomania" (film)
* Egotheism
* Empire-building
* God complex
* History of narcissism
* Messiah complex
* Micromanagement
* Narcissism of small differences
* Narcissistic leadership
* Narcissistic parent
* Narcissistic Personality Inventory
* Narcissus (mythology)
* On Narcissism (Freud essay)
* Sam Vaknin
* Self-love
* Self-serving bias
* Spoiled child
* The Culture of Narcissism (Lasch book)
* Workplace bullying

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Digital media use and mental health

Proposed or recognised diagnostic categories|

* Gaming disorder (Video game addiction)
* Problematic social media use
* Internet addiction disorder
* Problematic smartphone use
* Nomophobia
* Computer addiction
* Television addiction
* Internet sex addiction

Disciplines involved|

* Digital sociology
* Digital anthropology
* Psychiatry
* Psychology
* Neuroscience

Associated psychiatric conditions|

* Depression
* Anxiety
* Attention deficit hyperactivity disorder
* Bipolar disorder

Related concepts|

* Electronic media and sleep
* Screen time
* Digital detox
* Smartphone zombie
* Cyberbullying
* Media multitasking
* Online problem gambling
* Technostress
* Computer rage

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