January 18, 2018
What Is Narcissistic Personality Disorder? A Primer for Our Time

What Is Narcissistic Personality Disorder? A Primer for Our Time

by Jeanine Barone

Many of us possess at least a touch of narcissism. And with the advent of social media, what might once have been considered pretty self-obsessed behavior—taking repeated photos of oneself and publishing them for public viewing—aka the “selfie”—has become not only culturally acceptable but even expected.

​But there’s narcissism, and then there’s narcissistic personality disorder, which is a mental health condition. The campaign and election of Donald J. Trump has brought the latter to an unprecedented level of national prominence—largely due to numerous mental health professionals who have stepped forward to say they believe the president exhibits the hallmark traits of this disorder and therefore isn’t fit to govern the country.

One group of such professionals, led by a former psychiatry professor at Johns Hopkins University, recently formed an organization called Duty to Warn, a term that refers to a counselor’s or therapist’s responsibility to warn authorities or other third parties if a client poses a threat to himself/herself or another identifiable person. (It’s one of the few cases in which a mental health professional can breach client confidentiality.) The group’s Facebook page, which has more than 4,700 members, describes it as “a society dedicated to the proposition that Donald Trump is too seriously mentally ill to competently discharge his duties as president and must be removed according to the 25th Amendment.” Another group of almost three dozen mental health professionals signed a letter to the editor published in The New York Times in February 2017, affirming their belief that “the grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president.” (Such claims have met with some controversy; see inset below.)

What exactly is narcissistic personality disorder, and what makes it different from mere self-centeredness? Here’s a concise guide to this condition now commandeering our national headlines.

What is a personality disorder (and how is it different from personality)?

​Personality consists of a number of traits that together make each of us different in terms of our attitudes and values, how we interact with others and perceive ourselves. Personality also affects our expectations and reactions in different situations, including how we react to stress and how we solve problems. Just because, for example, some people are self-involved—which might lead us to colloquially label them “narcissists”—doesn’t mean they have narcissistic personality disorder. Personality disorders are different from personality traits in that they cause significant distress or impairment in one’s personal, social, or occupational functioning. People with personality disorders often experience great difficulty and emotional pain relating to interpersonal relationships, often going back to their teen or young adult years.

Narcissistic personality disorder is characterized by grandiosity, an urgent need for attention and praise, superficial interpersonal relationships, and a lack of empathy. People with the disorder think the “world revolves around them” and see themselves as superior to others despite not necessarily having the skills or attributes to meet their grandiose claims. Other hallmark traits include being manipulative and blaming others for things that go wrong. People with severe narcissistic personality disorder can become aggressive or angry seemingly out of the blue, but particularly when others don’t agree with their own outsized view of themselves. These characteristics lead to serious problems in many or all of the relationships in the person’s life.

How prevalent is narcissistic personality disorder?

Narcissistic personality disorder is among the least studied of all the personality disorders (there are 10 in total), but it’s estimated that about 6 percent of the U.S. population may have this condition. It’s more prevalent among men and younger adults; in fact, people ages 20 to 29 are three times as likely to fit the diagnostic criteria as those 65 or older, according to a paper published in the Journal of Clinical Psychiatry in 2008. The apparent greater prevalence of the disorder among young people may reflect developmental difficulties encountered as they move towards adulthood.

How is narcissistic personality disorder diagnosed?

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM-5—the “bible” of mental illness diagnosis—a person can be diagnosed as having narcissistic personality disorder if he or she exhibits at least five of the following nine characteristics. The traits must be stable over time and across different life situations:

  • A great desire to be the center of attention
  • Lack of empathy
  • Relationships that are based on exploitation or are superficial
  • Feelings of being exceptional or superior to others
  • Envy towards other people
  • Arrogance
  • A sense of entitlement
  • The belief that they are special
  • A fantasy that he or she has unlimited power or brilliance

In addition to the DSM criteria, clinicians may also rely on any of several personality tests to help diagnose narcissistic personality disorder, as well as to determine if other personality disorders may also be present.

Can a Mental Health Professional Really Diagnose Someone from Afar?

Headlines this year have teemed with declarations by mental health professionals that President Donald J. Trump has narcissistic personality disorder or various other mental illnesses. But those claims have met with their share of controversy.

What causes narcissistic personality disorder?

As with other personality disorders, some evidence suggests there’s a genetic component. Environmental factors, including how the individual was parented, may also play a role—especially if the parents were cold, aggressive, frustrated, and overprotective. As with so many other conditions, physical and mental, it’s most likely that personality disorders, including narcissistic personality disorder, result from an interaction between nature (genetics) and nurture (environment).

How is narcissistic personality disorder treated?

​The first-line treatment for narcissistic personality disorder and other personality disorders is psychotherapy, though medications are sometimes also used, including certain antidepressants, mood stabilizers, and antipsychotic drugs. Therapy can help people with narcissistic personality disorder to manage their symptoms and improve their level of functioning, though getting them to go—and to commit to ongoing treatment with the therapist—is sometimes a challenge. In some cases the therapist may also want to meet with the person’s family members, including spouses or partners.

Several types of psychotherapy are used in the treatment of narcissistic personality disorder. One approach, dynamic supportive psychotherapy, seeks to make people aware of their behaviors and to then coach them in other, more adaptive behaviors. It teaches skills to help the individual navigate social situations and to reduce negative impulsive behavior, such as lashing out at or demeaning others, and negative thought patterns. Another modality, mentalization-based treatment, focuses on self-reflection; the objective is for people to find out more about how they think and feel about themselves and others, how those thoughts and feelings influence their behavior, and how distortions in understanding themselves and others lead to maladaptive actions (although those actions are intended to maintain stability and manage feelings that the person cannot understand). In schema-focused psychotherapy, the therapist may at first interact with the “child side” of the individual while playing the role of parent. This is intended to deal with vulnerabilities that may be linked with the way a parent spoke to the person or behaved with them during their childhood. All three of these therapies draw from different aspects of other well-known approaches, including cognitive behavioral therapy and psychodynamic therapy.

Another type of therapy, known as dialectical behavior therapy, was originally developed to treat borderline personality disorder but is also used in some people with narcissistic personality disorder. This is a form of cognitive behavioral therapy that focuses on cultivating mindfulness, effectiveness in managing interpersonal relationships, regulation of emotions, and making positive changes in thoughts and behaviors.

For more information on narcissistic personality disorder or other personality disorders, an excellent starting place is MedlinePlus, run by the NIH’s National Library of Medicine.