One might call out a person who posts an excessive amount of selfies on social media or talks way too much about themselves a narcissist, but a true narcissist — the kind diagnosed by a psychiatrist — is actually a bit more than that.

A narcissist is essentially a person who is diagnosed with narcissistic personality disorder (NPD). The hallmarks of a clinical case of narcissism are selfishness at the expense of others, attention-seeking, and the lack of consideration for other people’s feelings. But behind this mask of extreme confidence lies a fragile self-esteem that’s vulnerable to the slightest criticism.

Going into more detail, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) — the handbook used by healthcare professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders — there are nine criteria for NPD.

These include:

1. grandiose sense of self-importance
2. preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3. belief they’re special and unique and can only be understood by, or should associate with, other special or high-status people or institutions
4. need for excessive admiration
5. sense of entitlement
6. interpersonally exploitative behavior
7. lack of empathy
8. envy of others or a belief that others are envious of them
9. demonstration of arrogant and haughty behaviors or attitudes

Alternatively, the DSM-5 handbook suggests that NPD is characterized by moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

• Identity
• Self-direction
• Empathy
• Intimacy

Am I a narcissist? The challenges of diagnosing NPD

Narcissistic personality disorder is highly variable and comes with a wide range of severity of pathology. Like many other mental health disorders, NPD is on a spectrum with some being more ‘narcissistic’ than others, and a diagnosis in real-life is not as easy as it might seem.

While the definition and criteria offered by the DSM-5 handbook capture important aspects of narcissistic pathology, some psychologists believe that these classifications fail to provide broader coverage of the individuals who receive the diagnosis in clinical practice.

In a 2015 review published in The American Journal of Psychiatry, psychologists wrote that the DSM-5 fails to address some cover psychological features of NPD, such as vulnerable self-esteem; feelings of inferiority, emptiness, and boredom; and affective reactivity and distress. In other words, narcissism isn’t all about an inflated sense of self, it can also describe a deflated sense of self.

“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,” wrote the authors of the study.

But what seems to characterize individuals with NPD across the board is a brittle sense of self that is somewhat removed from reality, rather than flexible and reality-based. This fragile sense of self is predicated on maintaining a view of oneself as exceptional.

The NPD individual is excessively reliant on external feedback and validation to support not only positive self-regard but also self-definition. This means that the NPD individual may display a dual strategy in his relationship with others. On the one hand, they have a profound need for others to support their sense of self, but mainly on a superficial level. On the other hand, engaging with other people on an authentic level may confront the NPD individual with the painful reality that others have attributes that they lack.

Subtypes of narcissistic personality disorder

In fact, some clinicians believe that the textbook narcissist, which is typically characterized by overt grandiosity, attention-seeking, entitlement, arrogance, and little observable anxiety, is merely a subtype of NPD — the thick-skinned, overt subtype.

For instance, another subtype is the vulnerable NPD, where grandiosity is cloaked in feelings of inferiority and deficiency. 

The two subtypes can be differentiated by the fact that those with more grandiose features tend to engage in superficial relationships organized to support self-esteem and self-definition, whereas those in the vulnerable subtype tend to withdraw from social situations in order to avoid the painful reality that others have attributes that they lack.

Besides the grandiose and vulnerable subtypes, there is a healthier group of individuals with narcissistic personality disorder, described as “high-functioning,” “exhibitionistic,” or “autonomous.” These are the kind of people who use some of the characteristics of NPD as adaptive rather than maladaptive traits in order to succeed in life. Thanks to their high level of functioning, at first glance individuals who fall under this subtype of NPD, may not appear as they suffer from a personality disorder, so their diagnosis may be overlooked.

Finally, there’s “malignant narcissism”. Patients with this subtype of NPD display prominent antisocial behavior, tend toward paranoid features, and take pleasure in their aggression and sadism toward others.

All subtypes share the tendency for self-regulatory needs that leave little room for genuine interest in the needs or feelings of others.

How many narcissists are there?

The prevalence of NPD is poorly understood, but many experts believe that it is one of the most common personality disorders. Estimates range from 1% to 5.3% in the general population.

Narcissism is rarely alone, though. NPD is frequently associated with other comorbidities, in particular with substance use disorders, bipolar disorder, and other personality disorders. In fact, NPD comorbidities are the main reason why individuals with narcissistic personality disorder even come to clinical attention.

Narcissistic personality disorder most commonly co-occurs with antisocial, histrionic, borderline, schizotypal, and passive-aggressive personality disorders.

What causes narcissism?

Scientists don’t know what causes NPD, but as is the case with other personality disorders, the causes are likely complex. NPD has been linked to:

• Environment ― psychologists have identified a relationship between excessive adoration or excessive criticism in childhood by a parent and the propensity to develop NPD later in life.
• Genetics ― inherited characteristics
• Neurobiology — the connection between the brain and behavior and thinking

NPD tends to affect more males than females. The first signs of NPD often begin in the teens or early adulthood.

Treatment for narcissistic personality disorder

Individuals with NPD generally believe that there isn’t anything wrong with them, so it is very unlikely they will seek treatment. However, they may be inclined to call for help due to symptoms of depression, drug or alcohol use, or another mental health problem caused by the comorbidities that often accompany NPD.

Due to the grandiosity and defensiveness that characterize narcissistic personality disorder, individuals with NPD will tend to be against acknowledging problems and vulnerabilities and make engagement in any form of psychotherapy difficult.

So far, the efficacy of psychotherapeutic and psychopharmacological treatment approaches for narcissistic personality disorder has never been systematically or empirically investigated — to the best of our knowledge.

However, there are empirically supported treatments for borderline personality disorder that have adaptations for narcissistic personality disorder. These include mentalization-based therapy, transference-focused psychotherapy, and schema-focused psychotherapy.

NPD can’t be ‘cured’, but psychotherapy can help an individual to:

• manage their emotions more effectively
• learn to take responsibility for their actions
• learn to build healthier relationships with others
• build up their self-esteem
• adjust their expectations of themselves and others
• understand the impact of their behavior on others