Narcissistic Personality Disorder (NPD) at a Glance
Narcissism, Pathological Narcissism, Narcissistic Personality Disorder (NPD), the Narcissist,
and Relationships with Abusive Narcissists and Psychopaths
By: Dr. Sam Vaknin, Author of "Malignant Self Love - Narcissism Revisited"
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What is Pathological Narcissism?
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Pathological narcissism is a life-long pattern of traits and behaviours which signify infatuation and obsession with one's self to the exclusion of all others and the egotistic and ruthless pursuit of one's gratification, dominance and ambition.
As distinct from healthy narcissism which we all possess, pathological narcissism is maladaptive, rigid, persisting, and causes significant distress, and functional impairment.
Pathological narcissism was first described in detail by Freud in his essay "On Narcissism" (1915). Other major contributors to the study of narcissism are: Melanie Klein, Karen Horney, Franz Kohut, Otto Kernberg, Theodore Millon, Elsa Roningstam, Gunderson, and Robert Hare.
What is Narcissistic Personality Disorder (NPD)?
Narcissistic Personality Disorder (NPD) (formerly known as megalomania or, colloquially, as egotism) is a form of pathological narcissism. It is a Cluster B (dramatic, emotional, or erratic) personality disorder. Other Cluster B personality disorders are the Borderline Personality Disorder (BPD), the Antisocial Personality Disorder (APD), and the Histrionic Personality Disorder (HPD). The Narcissistic Personality Disorder (NPD) first appeared as a mental health diagnosis in the DSM III-TR (Diagnostic and Statistical Manual) in 1980.
The ICD-10, the International Classification of Diseases, published by the World Health Organisation in Geneva  regards the Narcissistic Personality Disorder (NPD) as "a personality disorder that fits none of the specific rubrics". It relegates it to the category "Other Specific Personality Disorders" together with the eccentric, "haltlose", immature, passive-aggressive, and psychoneurotic personality disorders and types.
The American Psychiatric Association, based in Washington D.C., USA, publishes the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision (DSM-IV-TR)  and fifth edition , where it provides the diagnostic criteria for Narcissistic Personality Disorder (301.81, p. 669).
Both editions of the DSM define Narcissistic Personality Disorder (NPD) as "a pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in various contexts", such as family life and work.
The DSM specifies nine diagnostic criteria. Five (or more) of these criteria must be met for a diagnosis of Narcissistic Personality Disorder (NPD) to be rendered.
[In the text below, I have proposed modifications to the language of these criteria to incorporate current knowledge about this disorder. My modifications appear in bold italics.]
[My amendments do not constitute a part of the text of the DSM, nor is the American Psychiatric Association (APA) associated with them in any way.]
[Click here to download a bibliography of the studies and research regarding the Narcissistic Personality Disorder (NPD) on which I based my proposed revisions.]
Proposed Amended Criteria for the Narcissistic Personality Disorder
Prevalence and Age and Gender Features
According to the DSM IV-TR, between 2% and 16% of the population in clinical settings (between 0.5-1% of the general population) are diagnosed with Narcissistic Personality Disorder (NPD). Most narcissists (50-75%, according to the DSM-V) are men. The DSM V suggests that “between 0% and 6.2% of community samples” may be diagnosed with Narcissistic Personality Disorder based on the DSM-IV criteria.
We must carefully distinguish between the narcissistic traits of adolescents - narcissism is an integral part of their healthy personal development - and the full-fledge disorder. Adolescence is about self-definition, differentiation, separation from one's parents, and individuation. These inevitably involve narcissistic assertiveness which is not to be conflated or confused with Narcissistic Personality Disorder (NPD).
"The lifetime prevalence rate of NPD is approximately 0.5-1 percent; however, the estimated prevalence in clinical settings is approximately 2-16 percent. Almost 75 percent of individuals diagnosed with NPD are male (APA, DSM IV-TR 2000)."
From the Abstract of Psychotherapeutic Assessment and Treatment of Narcissistic Personality Disorder By Robert C. Schwartz,Ph.D., DAPA and Shannon D. Smith, Ph.D., DAPA (American Psychotherapy Association, Article #3004 Annals July/August 2002)
Narcissistic Personality Disorder (NPD) is exacerbated by the onset of aging and the physical, mental, and occupational restrictions it imposes.
In certain situations, such as under constant public scrutiny and exposure, a transient and reactive form of the Narcissistic Personality Disorder (NPD) has been observed by Robert Milman and labelled "Acquired Situational Narcissism".
There is only scant research regarding the Narcissistic Personality Disorder (NPD), but studies have not demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to it.
Comorbidity and Differential Diagnoses
Narcissistic Personality Disorder (NPD) is often diagnosed with other mental health disorders ("co-morbidity"), such as mood disorders, eating disorders, and substance-related disorders. Patients with Narcissistic Personality Disorder (NPD) are frequently abusive and prone to impulsive and reckless behaviours ("dual diagnosis").
Narcissistic Personality Disorder (NPD) is commonly diagnosed with other personality disorders, such as the Histrionic, Borderline, Paranoid, and Antisocial Personality Disorders.
The personal style of those suffering from the Narcissistic Personality Disorder (NPD) should be distinguished from the personal styles of patients with other Cluster B Personality Disorders. The narcissist is grandiose, the histrionic coquettish, the antisocial (psychopath) callous, and the borderline needy.
As opposed to patients with the Borderline Personality Disorder, the self-image of the narcissist is stable, he or she are less impulsive and less self-defeating or self-destructive and less concerned with abandonment issues (not as clinging).
Contrary to the histrionic patient, the narcissist is achievements-orientated and proud of his or her possessions and accomplishments. Narcissists also rarely display their emotions as histrionics do and they hold the sensitivities and needs of others in contempt.
According to the DSM-V, both narcissists and psychopaths are "tough-minded, glib, superficial, exploitative, and unempathic". But narcissists are less impulsive, less aggressive, and less deceitful. Psychopaths rarely seek narcissistic supply. As opposed to psychopaths, few narcissists are criminals.
Patients suffering from the range of obsessive-compulsive disorders are committed to perfection and believe that only they are capable of attaining it. But, as opposed to narcissists, they are self-critical and far more aware of their own deficiencies, flaws, and shortcomings.
Clinical Features of the Narcissistic Personality Disorder
The onset of pathological narcissism is in infancy, childhood and early adolescence. It is commonly attributed to childhood abuse and trauma inflicted by parents, authority figures, or even peers. Pathological narcissism is a defense mechanism intended to deflect hurt and trauma from the victim's "True Self" into a "False Self" which is omnipotent, invulnerable, and omniscient. The narcissist uses the False Self to regulate his or her labile sense of self-worth by extracting from his environment narcissistic supply (any form of attention, both positive and negative).
There is a whole range of narcissistic reactions, styles, and personalities – from the mild, reactive and transient to the permanent personality disorder.
Patients with Narcissistic Personality Disorder (NPD) feel injured, humiliated and empty when criticized. They often react with disdain (devaluation), rage, and defiance to any slight, real or imagined. To avoid such situations, some patients with Narcissistic Personality Disorder (NPD) socially withdraw and feign false modesty and humility to mask their underlying grandiosity. Dysthymic and depressive disorders are common reactions to isolation and feelings of shame and inadequacy.
The interpersonal relationships of patients with Narcissistic Personality Disorder (NPD) are typically impaired due to their lack of empathy, disregard for others, exploitativeness, sense of entitlement, and constant need for attention (narcissistic supply).
Though often ambitious and capable, inability to tolerate setbacks, disagreement, and criticism make it difficult for patients with Narcissistic Personality Disorder (NPD) to work in a team or to maintain long-term professional achievements. The narcissist's fantastic grandiosity, frequently coupled with a hypomanic mood, is typically incommensurate with his or her real accomplishments (the "grandiosity gap").
Patients with Narcissistic Personality Disorder (NPD) are either "cerebral" (derive their Narcissistic Supply from their intelligence or academic achievements) or "somatic" (derive their Narcissistic Supply from their physique, exercise, physical or sexual prowess and romantic or physical "conquests").
Patients with Narcissistic Personality Disorder (NPD) are either "classic" (meet five of the nine diagnostic criteria included in the DSM), or they are "compensatory" (their narcissism compensates for deep-set feelings of inferiority and lack of self-worth).
Some narcissists are covert, or inverted narcissists. As codependents, they derive their narcissistic supply from their relationships with classic narcissists.
Based on a survey of 1201 therapists and psychologists in clinical practice, Prof. Drew Westen of Emory University postulated the existence of three subtypes of narcissists:
1. High functioning or Exhibitionist: "(H)as an exaggerated sense of self-importance, but is also articulate, energetic, outgoing, and achievement oriented." (The equivalent of the cerebral narcissist).
2. Fragile: "(W)ants to feel important and privileged to ward off painful feelings of inadequacy and loneliness" (The equivalent of the compensatory, shy, inverted, or covert narcissist).
3. Grandiose or Malignant: "(H)as an exaggerated sense of self-importance, feels privileged, exploits others, and lusts after power." (The equivalent of the classic narcissist).
The common treatment for patients with Narcissistic Personality Disorder (NPD) is talk therapy (mainly psychodynamic psychotherapy or cognitive-behavioural treatment modalities). Talk therapy is used to modify the narcissist's antisocial, interpersonally exploitative, and dysfunctional behaviors, often with some success. Medication is prescribed to control and ameliorate attendant conditions such as mood disorders, or obsessive-compulsive disorders.
The prognosis for an adult suffering from Narcissistic Personality Disorder (NPD) is poor, though his adaptation to life and to others can improve with treatment.
Narcissistic Personality Disorder in the DSM V- Click HERE and HERE to Watch the Video
Abolish Narcissistic Personality Disorder (NPD) in DSM V? - Click HERE to Watch the Video
DSM V proposed diagnostic criteria for Narcissistic Personality Disorder available HERE.
Read more about the shortcomings of the DSM IV and how they are tackled in the DSM V - click HERE.
The DSM V (2013) re-defines personality disorders thus:
"The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits."
According to the Alternative DSM V-TR Model for Personality Disorders (2022, p.881), the following criteria must be met to diagnose Narcissistic Personality Disorder (in parentheses my comments):
Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following areas:
Excessive reference to others for self-definition and self-esteem regulation (narcissistic supply); exaggerated self-appraisal inflated or deflated, or vacillating between extremes (grandiosity, a cognitive distortion); emotional regulation mirrors fluctuations in self-esteem.
The narcissist keeps referring to others excessively in order to regulate his self-esteem (really, sense of self-worth) and for "self-definition" (to define his identity.) His self-appraisal is exaggerated, whether it is inflated, deflated, or fluctuating between these two poles and his emotional regulation reflects these vacillations.
(Finally, the DSM V-TR accepted what I have been saying for decades: that narcissists can have an "inferiority complex" and feel worthless and bad; that they go through cycles of ups and downs in their self-evaluation; and that this cycling influences their mood and affect; that they are emotionally exogenously dysregulated).
Goal-setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
The narcissist sets goals in order to gain approval from others (narcissistic supply; the DSM V ignores the fact that the narcissist finds disapproval equally rewarding as long as it places him firmly in the limelight.) The narcissist lacks self-awareness as far as his motivation goes (and as far as everything else besides.)
The narcissist's personal standards and benchmarks are either too high (which supports his grandiosity), or too low (buttresses his sense of entitlement, which is incommensurate with his real-life performance.)
Impairments in interpersonal functioning in either empathy or intimacy (should be: in both.)
Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimation of own effects on others.
The narcissist finds it difficult to identify with the emotions and needs of others, but is very attuned to their reactions when they are relevant to himself (cold empathy.) Consequently, he overestimates the effect he has on others or underestimates it (the classic narcissist never underestimates the effect he has on others - but the inverted narcissist does.)
Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.
The narcissist's relationships are self-serving and, therefore shallow and superficial. They are centred around and geared at the regulation of his self-esteem (obtaining narcissistic supply for the regulation of his labile sense of self-worth.)
The narcissist is not "genuinely" interested in his intimate partner's experiences (implying that he does fake such interest convincingly.) The narcissist emphasizes his need for personal gain (by using the word "need", the DSM V acknowledges the compulsive and addictive nature of narcissistic supply). These twin fixtures of the narcissist's relationships render them one-sided: no mutuality or reciprocity (no intimacy).
Pathological personality traits
Both the following pathological personality traits:
Antagonism characterized by grandiosity and attention-seeking
Grandiosity (an aspect of Antagonism)
Feelings of entitlement, either overt or covert; self-centredness; firmly holding to the belief that one is better than others; condescension towards others.
The aforementioned feeling of entitlement. The DSM V adds that it can be either overt or covert (which corresponds to my taxonomy of classic and inverted narcissist.)
Grandiosity is characterized by self-centredness; a firmly-held conviction of superiority (arrogance or haughtiness); and condescending or patronizing attitudes.
Attention-seeking (an aspect of Antagonism)
Excessive attempts to attract and be the centre of attention of others; admiration seeking.
The narcissist puts inordinate effort, time, and resources into attracting others (sources of narcissistic supply) and placing himself at the focus and centre of attention. He seeks admiration (the DSM V gets it completely wrong here: the narcissist does prefer to be admired and adulated, but, failing that, any kind of attention would do, even if it is negative.)
The diagnostic criteria end with disclaimers and differential diagnoses, which reflect years of accumulated research and newly-gained knowledge:
The above enumerated impairments should be "stable across time and consistent across situations ... not better understood as normative for the individual’s developmental stage or socio-cultural environment ... are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma)."
Trait and personality functioning specifiers may be used to record additional personality features that may be present in narcissistic personality disorder but are not required for the diagnosis.
For example, other traits of Antagonism (e.g., manipulativeness, deceitfulness, callousness) are not diagnostic criteria for narcissistic personality disorder (see Criterion B) but can be specified when more pervasive antagonistic features (e.g., “malignant narcissism”) are present.
Other traits of Negative Affectivity (e.g., depressivity, anxiousness) can be specified to record more “vulnerable” presentations. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of narcissistic personality disorder (Criterion A), the level of personality functioning can also be specified.
Goldman, Howard H., Review of General Psychiatry, fourth edition,1995.Prentice-HallInternational, London.
Gelder, Michael, Gath, Dennis, Mayou, Richard, Cowen, Philip (eds.), Oxford Textbook of Psychiatry, third edition, 1996, reprinted 2000. Oxford University Press, Oxford.
Vaknin, Sam, Malignant Self-love: Narcissism Revisited, tenth revised impression, 1999-2015. Narcissus Publications, Prague and Skopje.
Westen, Drew et al. Refining the Construct of Narcissistic Personality Disorder: Diagnostic Criteria and Subtypes (Posted at http://ajp.psychiatryonline.org/pap.dtl)
Narcissistic Personality Disorder - Diagnostic Criteria
Narcissistic Personality Disorder - Prevalence and Comorbidity
Narcissistic Personality Disorder - Clinical Features
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