Written by Diane Bauer, M.S.
Diane Bauer Therapy, PLLC

References to narcissism have become increasingly common in the media recently, with headlines describing both politicians and celebrities alike as narcissists. Is narcissism truly on the rise, or is the media simply focusing on the self-centeredness that is sometimes thought to be a hallmark feature of the disorder? While more common in men than women (50-75% of diagnosed cases are men), narcissistic personality disorder (NPD) is relatively rare, showing up in only about 1-6% of the general population.
At one time or another, we have all probably been somewhat more self-centered or really wanted to have things go our way. That’s pretty normal. So what makes one person self-centered and another narcissistic? We all have personality traits—the ingrained ways we experience, interact with, and think about everything that goes on around us. The patterns of our behavior and our ways of thinking develop from an early age and are influenced by our genes as well as our early experiences. These traits are dimensional rather than categorical, meaning their components are present in normal people but are accentuated in those with a personality disorder, to the point that they impair functioning or cause distress. These ingrained patterns of behavior and thinking are present from late adolescence or early adulthood (narcissism is not clinically diagnosed prior to adulthood), and when friends and loved ones are asked about particular symptoms, they immediately associate them with the individual—it’s like a light bulb comes on because the explanation fits so perfectly with their experience.
The essential features of NPD that set it apart from a relatively normal amount of self-centeredness are a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and shows up in a variety of contexts (at home, at work, at school, in finances, etc.). Individuals with NPD tend to have an exaggerated sense of entitlement. They may routinely overestimate their abilities while underestimating the contributions of others; even taking credit for others’ successes. They believe they are superior, special, or in some way unique and expect others to recognize them as such. They tend to have a distinct inability to tolerate criticism of any kind, often reacting with anger, rage, or even a defiant counterattack to anyone who is critical of them. They expect to be catered to; given whatever they want or feel they need, no matter the effect on others. They have little apparent understanding of the feelings and needs of others and are often seemingly oblivious to how their words and actions affect others. They typically don’t respect healthy boundaries in relationships and are rarely held accountable for their actions (perhaps because of the angry responses that may be brought about). These individuals are often estranged from their families or they may show patterns of broken relationships or difficulty forming long-term, intimate partnerships.
As with many other mental health conditions, the cause of NPD is unknown and thought to be highly complex. Researchers have come to believe that extreme parenting behaviors—either emotional or physical neglect or excessive and indulgent praise–may be partially responsible. It is also possible that genetics or psychobiology—the connection between the brain and behavior and thinking—may play a role in its development. Risk factors include parents who may have been unpredictable, unreliable, or uninvolved, a lack of affection and praise during childhood, neglect and emotional abuse in childhood, parental disdain for fears and needs expressed during childhood, manipulative behavior from parents or caregivers, and excessive praise or overindulgence. Children who learn from their parents that vulnerability is unacceptable may be at risk of losing their ability to empathize with others’ needs. They may also mask their emotional needs with egotistical behavior in order to make themselves less vulnerable to the hurt associated with the neglect or abuse they experience.
People with NPD may be unable to recognize that there is anything wrong in their lives because doing so doesn’t fit with their sense of themselves. While they may find their relationships unfulfilling, they likely believe the difficulties they are experiencing in these relationships are the fault of a partner. Because of the nature of the disorder, they may respond defensively when loved ones or concerned friends encourage them to seek treatment. The most likely time for seeking treatment is when symptoms of depression develop—often as a result of perceived rejection or criticism. Those with NPD are also at risk for substance abuse (particularly cocaine), alcohol abuse, and relationship difficulties, so these issues may also provide the impetus for seeking treatment. Perhaps unfortunately, no medications are available for the treatment of NPD. Psychotherapy is the most successful way to treat the disorder, but again, because personality traits can be difficult to change, therapy can take several years. In the short term, individual therapy can focus on issues of depression, substance abuse, low self-esteem, and shame that are commonly experienced. Longer term goals center around teaching empathy and life skills, changing patterns of thinking that distort self-image, and helping individuals learn to relate better to others in order to increase intimacy and connection in relationships. Family therapy typically brings the whole family together to explore conflicts, communication and problem solving to help cope and resolve lingering relationship problems.
Partners of NPD individuals are likely to be very aware there is a problem, all the while being unable to quite put their finger on the source of the problem. They may come to doubt their own perceptions of what is going on because of having been told repeatedly that their perceptions are wrong and that they are the ones with the problem (NPD individuals are often very skilled at portraying themselves as the victim to their partner’s villain). They may remember a partner who was exceptionally charming when they first met, without recognizing the charm as a form of manipulation. They are often caught up in simply trying to keep the peace in what seems to be world swirling with “crazy-making.” Couple therapy can be helpful in these situations, but on-going individual therapy for the person with NPD is necessary in order to maximize results for the couple. Individual therapy for the partner (or child of an NPD parent) can be beneficial as well.
Tempting as it may be, it is rarely helpful when partners and concerned loved ones attempt to diagnose an individual. Personality disorders are complex and tend to be some of the most difficult disorders to understand and diagnose correctly. Many who are diagnosed with NPD exhibit symptoms of at least one other personality disorder—histrionic PD, borderline PD, and antisocial PD being the most commonly co-occurring. If the symptoms you’ve read about here seem familiar, either for you personally or within a close relationship, please reach out and make an appointment to get your questions answered. Whatever the resulting diagnosis, the symptoms described signal a need for support and resources, and I’m happy to provide both.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders, Fifth Edition. Arlington, VA: American Psychiatric Association.

Mayo Clinic Staff. (n.d.). Narcissistic Personality Disorder.

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York: The
The Guilford Press.