Narcissistic personality disorder (NPD)

What is NPD?

Narcissistic personality disorder (NPD) is a mental health condition in which a person believes they are better than everyone else. While many people have narcissistic traits, people with NPD have problems that affect their lives, relationships and everyday life.

People with NPD may appear arrogant, with an inflated self-image and disregard for the feelings of others.

NPD is part of the cluster of personality disorders with symptoms of intense and unstable emotions and a distorted self-image. It usually starts in the early adult years and affects more men than women.

Narcissism, narcissistic personality types and NPD

Everyone can show narcissism from time to time —feeling self-important or not showing empathy, or being selfish, aggressive, egotistical or insensitive.

In extreme cases, people might have a narcissistic personality type, which means they feel very entitled, but their behaviour is still normal.

People with NPD are significantly impaired. They might look excessively to others to boost their self-esteem, they can’t feel empathy and they have trouble forming deep relationships.

NPD is a mental illness that affects all areas of life, since symptoms are present during work and at home. It can be hard for others to tolerate the symptoms of NPD, which can mean the sufferer becomes isolated.

The difference between NPD and general narcissism is that NPD doesn’t change over time, and isn’t caused by a medical condition or drugs. You don’t grow out of it, and it can cause significant distress.

What are the symptoms of NPD?

People with NPD have a very exaggerated sense of their own importance. Key symptoms include:

• feelings of grandiosity (being superior)
• fantasising about power, beauty, success and intelligence
• exaggerating achievements and abilities
• constantly seeking attention and admiration
• being very sensitive to stress
• superiority, specifically towards people perceived as ‘lower’ in status
• inflated sense of entitlement
• obsession with class and status
• believing that others are envious of them
• great pride in the accomplishments of children or family
• expecting constant praise and recognition for achievements
• unrealistic goal setting

People with NPD have trouble handling criticism and can feel hurt easily. They may not be able to admit they have done anything wrong, and can get very angry if their orders or directions are not followed by others.

They also have problems with relationships which may be due to:

• inability to listen to others
• lack of awareness regarding others
• exploiting others for personal gain
• lacking empathy, especially for perceived weaknesses
• strong desire for control over relationships
• envy for those perceived as being of a higher status
• distant, practical manner in personal relationships
• can ‘write off’ friends permanently over small or imagined issues

People with NPD are at increased risk of using drugs and alcohol and withdrawing socially.

They may have feelings of deep insecurity beneath an arrogant exterior. With effective treatment, it is possible for people to learn to change their behaviours and have more positive relationships.

What causes NPD?

As with many personality disorders, the exact cause of NPD is unknown. It is probably a mixture of genes, early childhood experiences and psychological factors.

Early childhood risk factors include excessive praise or judgement by parents, trauma or abuse.

Low self-esteem and problems handling stress can also contribute to NPD.

Although there is no one answer to the question of what causes NPD, professionals agree that the sooner treatment begins, the better a person’s chance for an improved quality of life.

When should I see my doctor?

It can be difficult for someone with NPD to seek treatment since they generally do not recognise they have a problem. The first step to recovery is for the person with NPD to become aware that their behaviour is affecting their life and relationships.

You should seek help if you or someone you know has the symptoms above and is struggling to manage their relationships or their lives. Signs you should see a doctor are:

• feeling depressed or anxious
• having mood swings
• abusing drugs or alcohol
• thinking or talking about self-harm or suicide

If you or someone you know has NPD and you think there is any immediate danger of suicide, then please call triple zero (000) and ask for an ambulance. Don’t leave the person alone until help arrives.

How is NPD diagnosed?

A doctor will do an initial mental health assessment and may carry out physical examinations to ensure no physical illness is causing the symptoms.

There is no specific test for NPD. For a diagnosis of NPD, people must have at least 5 of the following criteria:

• an exaggerated sense of self-importance
• fantasies of great success, power, attractiveness, beauty or ideal love
• believing themselves to be special, and only able to be understood by others who are also special
• an increased sense of entitlement
• a need for constant admiration or attention
• taking advantage of others, envying others, or believing others envy them
• arrogance or haughtiness
• a lack of empathy
• envy towards others, or believing others are envious of them

The doctor will talk to the person, get to know them and ask some questions to understand their history and how severe the symptoms are. Sometimes it may take weeks or months to be diagnosed.

How is NPD managed?

If you have NPD traits and no other cause is found, the doctor may refer to a psychiatrist or psychologist to help draw up a mental health care plan.

Psychotherapy, or talking to a therapist, is the most useful treatment approach, although more research is required to determine the most effective therapies. The aim is to develop a more realistic self-image and enable the person to relate to others more positively. The type of therapy used can include:

• Psychodynamic therapy — long-term individual therapy that helps a person to understand their behaviours, moods and disruptive thoughts. These insights can help them find better ways to relate to others.
• Cognitive behaviour therapy (CBT) — helps people identify negative, unhelpful behaviour patterns and replace them with more productive and positive ones.
• Family or marital therapy — NPD can affect families. Coming together for a session can help people in dealing with relationships, with problem solving solutions and positive communication.

There’s no specific medicine to treat NPD. However, people with NPD sometimes also develop depression or anxiety, and in such cases antidepressant medications may help.

If you are concerned about suicide risk for a person with NPD, then seek medical advice urgently.