July 17, 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—for instance, repeatedly takingphotos of oneself (a.k.a. the “selfie”)and posting them online for public viewing—has become not only culturally acceptable but even expected, at least in some circles.

​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.

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 early 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. [Editors note: In January 2018, the White House physician announced that the president passed a standard test for memory and cognition as part of his medical checkup; such tests do not assess personality disorders, however.]

What exactly is narcissistic personality disorder, and how is it different from mere self-centeredness? Here’s a concise guide to this now-newsworthy condition.

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 in dealing with interpersonal relationships, starting as early as childhood.

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.

As with other personality disorders, evidence suggests that both genetics (“nature”) and environmental factors (“nurture”) are involved. Upbringing seems to play a significant role.

How is narcissistic personality disorder diagnosed?

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM-5 (considered 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 of other people, or feeling that he or she is envied by others
  • Arrogance
  • A sense of entitlement
  • The belief that he or she is 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 are also 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.

How common is it?

Narcissistic personality disorder is among the least studied of all the personality disorders (there are 10 in total, including paranoid and obsessive-compulsive). It’s estimated that up to 6 percent of Americans have this condition, with a higher prevalence 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 greater prevalence among young people may reflect developmental difficulties they encounter; apparently many of them outgrow the disorder.

How is it 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 personality disorders, a good starting place is MedlinePlus, run by the NIH’s National Library of Medicine.