Many people may be familiar with the casual use of the term narcissist, referring to a person who is very self-centered, boastful and hungry for attention and admiration. However, narcissistic personality disorder, a condition described in the DSM-5-TR*, is more severe, persistent and problematic.

Narcissistic personality disorder is complicated and nuanced. It is defined as a pervasive pattern of grandiosity (sense of superiority in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and occurring in a variety of contexts (APA 2022; see symptom list below). An estimated 1% to 2% of the U.S. population has narcissistic personality disorder (Weinberg & Ronningstam, 2022).

In addition to grandiosity, narcissistic personality disorder has a significant vulnerability aspect, and individuals may alternate between the two (Edershile 2022). Vulnerability may make individuals very sensitive to criticism or defeat and although they may not show it, those experiences may leave them feeling ashamed, degraded and empty. People with the disorder may react to criticism or defeat with disdain and defiance, or with social withdrawal or an appearance of humility, which masks the grandiosity (APA 2022). Although they seem like quite different traits, researchers have found that both aspects of narcissism have in common selfishness, deceitfulness and callousness (Kwon 2023).

One review study highlighted the variability in the disorder, noting that “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” (Caligor et al, 2015). Individuals with narcissistic personality disorder can be competent and high-functioning with professional and social success. Others can have problems functioning, low self-confidence and difficulty tolerating criticism or defeat.

People with narcissistic personality disorder often have relationship difficulties because of problems related to self-preoccupation, need for admiration, and insensitivity to others (APA 2022). They are also more likely to have other conditions and related problems, including increased distress, depression and anxiety and substance use disorders. Narcissistic personality disorder is also associated with increased risk for legal, work and relationship problems (Weinberg and Ronningstom, 2022).

While many people may have traits that might be considered narcissistic, that is not the same as narcissistic personality disorder. “Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute narcissistic personality disorder” (APA 2022). In addition, the DSM-5-TR notes that while some narcissistic traits may be common in adolescents, they “do not necessarily indicate that the individual will develop narcissistic personality disorder in adulthood.”

While research is limited, studies show that people with narcissistic personality disorder can improve, but the improvement is gradual and slow. Several treatments have been developed for the condition and they share common aspects, such as setting clear, realistic goals; attention to relationships and self-esteem; and building- the clinician-patient alliance (Weinberg& Ronningstam, 2022).