Narcissistic Personality Disorder: Diagnostic and Clinical Challenges

Diagnostic confusion surrounding narcissistic personality disorder reflects the disorder’s highly variable presentation and the wide range of severity that can characterize narcissistic pathology. 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. Given this heterogeneity, it is far from self-evident what such individuals could have in common to justify a shared diagnosis. The DSM-5 criteria (Table 1) to some degree sidestep this question by providing a rather narrow and homogeneous definition of narcissistic personality disorder characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, entitlement, and lack of empathy. However, while these criteria capture important aspects of narcissistic pathology, they provide inadequate coverage of the broad population of individuals who receive the diagnosis in clinical practice (9–11), and they fail to cover core psychological features of the disorder, including vulnerable self-esteem; feelings of inferiority, emptiness, and boredom; and affective reactivity and distress (11). Furthermore, because DSM-5 criteria are, a priori, limited to observable features of psychopathology, the description of narcissistic personality disorder in Section II of DSM-5 does not address underlying psychological structures or dynamic constellations that can be seen to organize and unify the various presentations of the disorder.

Although DSM-5 describes a single, relatively homogeneous syndrome, there is a rich literature supporting the existence of different subtypes of narcissistic personality disorder (12–22). The clinical vignettes we provide here of four patients diagnosed with narcissistic personality disorder illustrate both the variable presentation of the disorder with regard to descriptive features (“subtypes”) and the broad spectrum of severity of pathology associated with the disorder. Typical presentations of narcissistic personality disorder are the grandiose, “overt,” subtype, corresponding closely to the DSM-5 criteria and illustrated in the vignettes by Mr. B; the vulnerable, “covert,” subtype, less well covered in current diagnostic criteria, illustrated by Mr. C; and the healthier, “high-functioning” subtype illustrated by Mr. A.

The grandiose, thick-skinned, overt subtype is characterized by overt grandiosity, attention seeking, entitlement, arrogance, and little observable anxiety. These individuals can be socially charming, despite being oblivious to the needs of others, and are interpersonally exploitative. In contrast, the vulnerable, “fragile” or thin-skinned, covert subtype is inhibited, manifestly distressed, hypersensitive to the evaluations of others while chronically envious and evaluating themselves in relation to others. Interpersonally these individuals are often shy, outwardly self-effacing, and hypersensitive to slights, while harboring secret grandiosity. Both types are extraordinarily self-absorbed. Many individuals with narcissistic personality disorder fluctuate between grandiose and depleted states, depending on life circumstances, while others may present with mixed features (11, 15, 17, 22). In addition to the grandiose and vulnerable subtypes, there is a healthier group of individuals with narcissistic personality disorder, described as “high-functioning,” “exhibitionistic,” or “autonomous.” These individuals, illustrated by Mr. A, are grandiose, competitive, attention seeking, and sexually provocative, while demonstrating adaptive functioning and using their narcissistic traits to succeed. Because of their high level of functioning, at first glance individuals in this group may not appear to have a personality disorder, and the narcissistic personality disorder diagnosis can be overlooked on diagnostic assessment.

An appreciation of the various subtypes of narcissistic personality disorder leads to the question of what are the core psychological features that define narcissistic personality disorder and that can in turn be relied upon to inform clinical assessment and treatment planning. This issue is addressed to some degree in the alternative model for conceptualizing personality disorders developed by the DSM-5 Work Group and included in Section III of DSM-5. This model goes beyond the familiar focus on the descriptive features of different personality disorders to emphasize additionally the role of impairment of self and interpersonal functioning in personality pathology. For narcissistic personality disorder, Section III identifies deficits in self-definition, self-esteem and affect regulation, and consolidation of internal goals and standards as core features of the disorder; interpersonal relations are “functional,” serving to support the sense of self and/or to provide personal gain, and capacity for intimacy is lacking (Table 2).

Our own approach to characterizing and understanding narcissistic personality disorder is compatible with the alternative model developed by the DSM-5 Work Group and also with psychodynamic models of narcissistic personality disorder based in object relations theory. From a psychodynamic perspective, a specific form of self or identity dynamic is at the core of narcissistic pathology (15). Rather than the flexible and reality-based self-experience that characterizes normal identity formation, the sense of self in narcissistic personality disorder is brittle and somewhat removed from reality; what characterizes narcissistic personality disorder across the spectrum is a more or less fragile sense of self that is predicated on maintaining a view of oneself as exceptional. This characterization applies not only to grandiose narcissists, but also to those in the vulnerable subtype, where grandiosity is cloaked in feelings of inferiority and deficiency. Maintaining a grandiose sense of self can provide a more or less stable self-experience for the individual with narcissistic personality disorder, but comes at a cost, requiring a retreat from or denial of realities that do not support grandiosity, and leaving the individual excessively reliant on external feedback to support not only positive self-regard but also self-definition. The specific pathology of identity formation that characterizes narcissistic personality disorder also lends itself to characteristic disruptions in interpersonal functioning. On the one hand, individuals with narcissistic personality disorder often have a profound need for others to support their sense of self and also to help with self-esteem regulation. On the other hand, genuine engagement with others can threaten the stability of the grandiose sense of self, by confronting the individual with the painful reality that others have attributes that they lack. As a result, those with more grandiose features tend to engage in superficial relationships organized to support self-esteem and self-definition, while those with more vulnerable features tend to withdraw from social situations; for both types, self-regulatory needs leave little room for genuine interest in the needs or feelings of others.

The prevalence of narcissistic personality disorder remains poorly defined, reflecting the lack of clarity around the diagnosis. Commonly cited prevalence estimates range from 0% to 5.3% in the general population (11). Prevalence in clinical samples has been reported to range from 1% to 17% (11). In a recent large adult community sample, risk factors included male sex, younger age, and single marital status (2).

Narcissistic personality disorder is frequently comorbid with other disorders, particularly substance use disorders, bipolar disorder, and other personality disorders (2, 23, 24), and comorbid disorders are often what first brings individuals with narcissistic personality disorder to clinical attention. The degree of comorbidity is linked to severity (25). Narcissistic personality disorder most commonly co-occurs with antisocial, histrionic, borderline, schizotypal, and passive-aggressive personality disorders (3); comorbidity with antisocial personality disorder has the most profound negative impact on prognosis.

Grandiose and vulnerable narcissistic subtypes are associated with different patterns of comorbidity (22). Depression and anxiety are more common in the vulnerable narcissistic group, as are nonsuicidal self-injury and suicide attempts (16, 17, 19). In contrast, those with the grandiose subtype or in grandiose states may be relatively free of subjective distress unless confronted with professional or interpersonal failures (15, 18). Grandiose traits tend to be related to substance abuse and comorbidity with antisocial and paranoid personality disorder (19).

Individuals with narcissistic personality disorder constitute some of the highest-functioning patients seen in outpatient settings and also some of the most impaired and intractable among patients seen in emergency departments and on inpatient units. In fact, of all the personality disorders, narcissistic personality disorder spans the broadest spectrum of severity (15). As a result, it is useful to distinguish not only between grandiose/overt and vulnerable/covert clinical presentations, but also among different levels of severity of narcissistic personality disorder. In general, as severity of narcissistic pathology increases, aggression, which can be directed at oneself as well as others, becomes more evident, interpersonal functioning deteriorates, and deficiencies in moral functioning become increasingly prominent, posing significant challenges to clinical management (26, 27). More severe forms of narcissistic personality disorder challenge clinicians to limit patients’ destructive and self-destructive behavior. In addition, it is necessary to minimize secondary gain (benefits derived from being ill), which often involves insisting that patients seek appropriate employment and may require involvement of family members in treatment.

At the highest level of functioning, patients like Mr. A are able to achieve the admiration necessary to gratify their grandiose needs. These individuals may function successfully, although they may be susceptible to breakdowns in response to setbacks or advancing age. Like Mr. A, psychopathology may be evident primarily in a transactional view of intimate relations, which are characterized by superficiality and lack of genuine concern for the needs or the feelings of the other. Individuals in this group rarely seek treatment; when they do, it is often only at the insistence of significant others or during an acute crisis.

At the middle level of functioning, patients like Mr. B present with an obviously distorted, grandiose sense of self and have little interest in intimacy. These individuals may function adequately or even well professionally, despite significant interpersonal difficulties, or they may refuse to work, especially if they do not have access to narcissistically gratifying employment. Mr. B demonstrates grandiosity in his refusal to take on work he sees as beneath him, preferring to be unemployed, entitlement in his demands for medication in the emergency department, and financial exploitation of his parents and girlfriend. Problems in his sense of self are joined with a view of others as a means to an end rather than a source of mutual gratification. Motivation for treatment can be limited; Mr. B would likely have no interest in treatment unless his family demanded it as a condition of continued financial support.

At a lower level of functioning are patients like Mr. C, who present with comorbid borderline personality traits. In contrast to the higher-functioning group, these individuals exhibit a sense of self that is poorly defined and unstable; they frequently oscillate between pathological grandiosity and suicidality. Mr. C demonstrates self-directed aggression in his noncompliance with diabetes care, antisocial features to the extent that he misrepresents the cause of his hyperglycemia to his physicians, and extremely poor interpersonal functioning characterized by a lack of interest in relationships. In addition to demonstrating features of lower-level narcissistic pathology, Mr. C presents the challenge of vulnerable narcissism, appearing submissive and inadequate, but with a self-concept based on a covert sense of superiority. The gap between an unrealistic and extremely fragile sense of self and objective reality leads to a lack of engagement in the world, as any meaningful contact with others (including treatment providers) challenges his covert grandiosity.

Finally, at the greatest level of severity are those like Ms. D who suffer from “malignant narcissism” (28). The illnesses of these patients are characterized by the typical symptoms of narcissistic personality disorder; however, these patients also display prominent antisocial behavior, tend toward paranoid features, and take pleasure in their aggression and sadism toward others. Individuals in this group are the most difficult to treat: chronic lying and the sadistic pleasure in controlling and even frightening and intimidating clinicians can overwhelm any possibility of working therapeutically. In addition, secondary gains, which can be financial or interpersonal, provide a powerful motivation for the patient to maintain the status quo; often there is no hope for change unless the treatment team works with the patient’s social system to limit or eliminate secondary gain.

Because of the sometimes subtle presentation of narcissistic personality disorder, especially at the higher-functioning end of the spectrum, and because of the centrality of interpersonal difficulties in the disorder, a systematic clinical interview may be the most reliable way to diagnose narcissistic personality disorder. Kernberg’s structural interview (29) is one such clinical interview, and it is also available in modified form as a semistructured interview (30). While structured assessments for narcissistic personality disorder, in both self-report and structured interview formats, have demonstrated reliability and utility for research, they add little to the interview of a skilled clinician.

In the clinical interview, focusing on the patient’s description of significant others can help in diagnosing narcissistic personality disorder. These descriptions are characteristically dismissive or derogating or, alternatively, colored by idealization. Most striking, however, is the markedly superficial and vague, shadowy quality of the narcissistic individual’s experience of others. In addition, individuals with narcissistic personality disorder demonstrate a tendency to describe others in terms of how others are similar to or different from themselves. In contrast, the narcissistic individual’s sense of him- or herself may be more intact and nuanced, albeit colored by grandiosity or self-deprecation. The clinician’s personal reactions to the individual with narcissistic personality disorder can call attention to the diagnosis. Common reactions to patients with narcissistic personality disorder include feeling idealized and pressured to provide a magic cure, feeling belittled and devalued, feeling treated like someone who is incompetent and has nothing to offer, or feeling like a sounding board, ignored, without recognition of the clinician as an individual or any interest in what he or she might have to say (19, 31, 32).

The differential diagnosis for narcissistic personality disorder includes bipolar illness, substance abuse, depressive disorders, especially treatment refractory depression, and anxiety disorders, as well as other personality disorders. All are frequently comorbid with narcissistic personality disorder, complicating diagnostic and clinical decision making; it is often unclear whether symptoms of anxiety or depression, for example, reflect a comorbid diagnosis or are primarily an expression of personality pathology. While manic states can mimic many of the features of grandiose narcissism, the admiration seeking and devaluation of others characteristic of narcissistic personality disorder are typically absent in manic individuals. One can imagine that Mr. A, when excited by a new business idea, might demonstrate the kind of expansiveness and exuberant enthusiasm seen in hypomania. In this setting, his need to have his superior creativity and effectiveness admired by others would help to distinguish his behavior from that of someone who is hypomanic. Chronic substance abuse can affect psychological functioning to simulate narcissistic personality disorder; the individual with a chronic substance use disorder may become exploitative, self-focused, lacking in empathy, and ruthless, often in conjunction with antisocial features. This syndrome could potentially be at play with Mr. B, and establishing the narcissistic personality disorder diagnosis would require careful assessment of his substance abuse history as well as of his personality functioning across time. Symptoms associated with major depression, dysthymia, social anxiety, and generalized anxiety disorder overlap with features of vulnerable narcissism. In this setting, one can avoid missing the narcissistic personality disorder diagnosis by careful evaluation of the patient’s sense of self and interpersonal functioning. For example, despite Mr. C’s complaints of depression and social anxiety, his covert grandiosity is incompatible with a diagnosis of a major affective or anxiety disorder alone. Similarly, Ms. D’s grandiosity and entitlement do not fit with the diagnosis of major depression, despite her many years of treatment. In addition, the absence of all meaningful relationships demonstrated by both Mr. C and Ms. D would be difficult to account for on the basis of depression and anxiety.

The personality disorders most commonly in the differential diagnosis for narcissistic personality disorder are histrionic, borderline, and antisocial. It is the characteristic grandiosity and need for admiration that most clearly distinguish narcissistic personality disorder from these other diagnostic groups. Narcissistic personality disorder and borderline personality disorder can be further distinguished by the relative instability of the sense of self, along with the impulsivity and self-destructiveness of borderline personality disorder. Mr. C, who presents with comorbid borderline and narcissistic personality disorders, illustrates these features. Histrionic personality disorder and narcissistic personality disorder are both characterized by the need to be the center of attention, but individuals with histrionic personality disorder have a greater capacity for dependent relations than do those with narcissistic personality disorder, and they are more emotionally expressive and less dismissive of others. Despite his superficially good interpersonal functioning and attention seeking, Mr. A can be distinguished from the individual with histrionic personality disorder on the basis of his callous and self-serving attitude toward the women in his life, his lack of overt emotionality, and his view of himself as exceptional. Antisocial personality disorder and narcissistic personality disorder share the traits of exploitation, superficiality, and lack of empathy, but even at the more severe end of the spectrum, individuals with narcissistic personality disorder do not demonstrate the total breakdown of moral functioning and absence of any capacity for loyalty that typifies antisocial personality disorder, nor is narcissistic personality disorder typically associated with the history of childhood conduct disorder that is common in antisocial personality disorder.

The efficacy of psychotherapeutic and psychopharmacological treatment approaches for narcissistic personality disorder has not been systematically or empirically investigated (3). Clinical practice guidelines for the disorder have yet to be formulated, and psychopharmacologic intervention is symptom driven. Regardless of severity, the grandiosity and defensiveness that characterize narcissistic personality disorder militate against acknowledging problems and vulnerabilities and make engagement in any form of psychotherapy difficult (33).

In patients presenting with major psychiatric disorders, co-occurring narcissistic personality disorder is known to increase the likelihood of treatment dropout and may slow symptom change (34, 35). With this group of patients, discussion of diagnostic issues, including the contribution of personality pathology to the symptom picture, should precede initiation of treatment. Discussion of personality pathology helps to establish realistic expectations on the part of the patient and opens the door to discussion of treatments for underlying narcissistic pathology. Failure to have this sort of discussion can result in polypharmacy or multiple courses of ineffective treatments devoted to chasing refractory symptoms, as exemplified by the case of Ms. D in the vignettes.

When it comes to treatments targeting narcissistic personality disorder per se, current treatment recommendations are based largely on clinical experience and theoretical formulations. Psychodynamic formulations have led to the proliferation of different treatment approaches, and case reports suggest that these treatments can be effective for some patients. Most influential have been those of Kernberg (36, 37) and Kohut (38, 39), each of which focuses on clinical developments in the relationship between therapist and patient in long-term psychotherapy. In the absence of empirically supported treatments for narcissistic pathology, it is common practice to utilize efficacious treatments for near-neighbor disorders, typically with treatment modifications based on theoretical and clinical rationales regarding differences in the disorders (22). Thus, for patients with narcissistic personality disorder, we recommend referral for empirically supported treatments for borderline personality disorder that have adaptations for narcissistic personality disorder. In particular, we recommend mentalization-based therapy (40), transference-focused psychotherapy (41–43), and schema-focused psychotherapy (44). All three treatments target psychological capacities thought to underlie and organize descriptive features of narcissistic personality disorder. Dialectical behavioral therapy (45) is an additional option for patients with comorbid borderline personality disorder and significant self-destructive acting-out behaviors. All are longer-term treatments that require specialized training of practitioners.

Narcissistic personality disorder is a challenging clinical syndrome; it has a variable presentation, is difficult to treat, and complicates the treatment of commonly co-occurring disorders. In the absence of expertise or resources for longer-term treatment of personality disorders, there are specific approaches and techniques that can be implemented to improve general clinical management of patients with the disorder. Based on our review of the literature and clinical experience, we make the following recommendations:

The authors thank their colleagues at the Personality Disorders Institute and the Personality Studies Institute, particularly Drs. Otto Kernberg, Diana Diamond, and Barry Stern. They also thank Jacqueline Proszynski for her assistance with the manuscript.