Understanding Narcissism and Narcissistic Personality Disorder (NPD)

It seems no matter where I turn, I hear variations of the term “narcissist” or “narcissism”.  It is becoming an endemic part of society’s lexicon when describing less than desirable behaviors and attitudes of another person. In Western societies, and for those who adopt a Western view, being a strong, confident, and dominant male is often pathologized, while those same qualities can also manifest themselves in women and be pathologized in a different way.  One of the issues with the widespread misuse of the terms “narcissism” and “narcissist” is that we oftentimes trivialize or fail to understand and support the true victims of narcissistic abuse.

Over the next three months, I will be providing a broad overview on narcissism (both healthy and pathological forms) and Narcissistic Personality Disorder (NPD).  More specifically, we will address the following topics:

1. What is NPD, and what is the difference between narcissism and NPD?

2. The different types of Narcissists

3. The Narcissistic Relationship Cycle, including trauma bonds and how to recognize and break them

This is neither intended to be an extensive review of the literature nor an exhaustive exploration of narcissism.  The purpose of this brief series is to raise awareness and to provide psychoeducation.

So, let’s begin…

“Ugh, he is so confident. I bet he is a narcissist.”

I hear this, and many similar statements, in the course of the work I do.  The internet and the ease of accessing information is both a blessing and a curse.  When we want to know something quickly, Google has the answer, whether we want to know who an actor/actress is or want to understand the behaviors of others in our lives.

Unfortunately, this leads to the proliferation of misinformation.  The words we use to describe others and their behaviors are important.  We often use clinical words and concepts very colloquially; these words are often devoid of scientic basis and the meaning is inevitably skewed.  Additionally, we use these clinical words and concepts often to describe behaviors that we do not like about ourselves and/or others.  While I understand the temptation, it is important to understand the meaning behind the words we are using.  When we use clinical terms inappropriately, we delude the actual meaning and therefore the actual lived experiences of others, whether they are the one with narcissism or NPD or someone who is a victim of narcissistic abuse.  Our words matter.

There are several theorists that have commented upon and explained narcissism.  For this series, I will focus on the work of Heinz Kohut as his theory is where I ground myself and practice from clinically.  We start below with an exploration of where the term narcissism originated from, and brief overviews of what narcissism and Narcissistic Personality Disorder are.

So, what is the origin of the term “narcissism”?  It comes from Greek mythology.  The story goes that a man named Narcissus fell in love with his own reflection, so much so that even a Love Nymph, named Echo, could not distract Narcissus from self-admiration.  It is believed he was cursed by the Goddess Nemesis to only experience unrequited love, just as he had done to the many he had spurned.  Thus, Narcissus fell in love with his own image, falling more and more every time he caught a glimpse of his image, yet it never fulfilled him, and always left him feeling empty (Levy et al., 2011).  This is our earliest framework for narcissism.

In the early 1900’s, Isidor Sadger asserted the difference between healthy and pathological narcissism, which would later be validated by other theorists, such as Heinz Kohut (Levy et al., 2011).

Narcissism versus Narcissistic Personality Disorder

Narcissism is a trait, while NPD is a pervasive pattern of behaviors that impacts all areas of life and functioning.  It is possible to have narcissistic traits and not meet criteria for NPD.  What is important to note about diagnosis and the manual used by clinicians for diagnosis (DSM 5 TR) is that the DSM 5 TR represents deviations from “normal” functioning – either in too much or too little of what is expected in the normal course of being a human.  For example, humans experience depression, but not every human will be diagnosed with Major Depressive Disorder.  The same is true for narcissism and NPD – we can have one without the other.  There is a spectrum and dimensionality to understanding narcissism that ranges from healthy to pathological. 

I am profoundly influenced by Heinz Kohut.  He believed that narcissism, which he defined as a complete internal self-focus, was normal and expected in early development.  In fact, others suggest that healthy narcissism helps create the foundation for several inter and intrapersonal skills: healthy entitlement, empathy, desire for affiliation and relation to others, and creativity (Ronningstam, 2011).  

Think about the excitement of a child coming home with a piece of paper and haphazard crayon lines – the child thinks, “Surely, this is the best artwork ever made!”  Ideally, the caregiver responds favorably, praises the child, and displays the artwork on the refrigerator or other prominent place in the house for all to see.  “Did you see my masterpiece?” asks the child.  We exclaim, “It belongs in an art museum!”  This is expected and considered healthy in the child to be narcissistic in this way.  However, and importantly, this need for such attention does need to taper off over time – less and less do we put every drawing up, and we become discerning.  This has implications for the child to learn that everything they produce may not be great, perfect, and admired, and how to regulate disappointment, while maintaining a healthy self-esteem.  Children, however, need to be able to come to caregivers in all circumstances, success, failure, and everything in between and receive empathy. 

Kohut suggested that pathological narcissism was due to an unresolved, and even disrupted, development in curtailing and providing shape to a child’s grandiose belief in the self.  When narcissism becomes pathological, and never matures from the early crayon drawing days, the young adult to adult, will excessively seek out praise and admiration.  It was never tempered. 

Naturally, children look up to their parents, however, when our caregiver fails to provide an empathic experience for us, we psychologically suffer.  Kohut referred to this as an “empathic failure.”  The child has no feedback about what is appropriate in terms of wishes, desires, and aspirations.  The child also never learns how to experience and manage feelings of disappointment, frustration in goal attainment, etc.  It is believed that they may become ashamed of their desires, and psychologically this part of themselves fails to integrate with who they are.  In later years, this may look like the young adult who feels he does not need to prepare for work for he believes his work is great, and once questioned, cannot receive this; or this may look like the young adult who is unable to seek out his desires without feeling profound shame.  Without early life experiences to help us discern what is appropriate, we continue to show up in the world as a self-centered child (Ronningstam, 2011). More and more, we may need to see narcissism as a trait that exists within us healthily, and there are some who have too much or too little (South et al., 2011).

There is research to suggest, and to support, the influence of early attachment experiences upon the development of pathological/unhealthy narcissism.  For example, according to van Schie et al., (2020), when childhood experiences related to discipline were remembered as overprotective, overvalued, and lenient, these were associated with higher levels of grandiose and vulnerable pathological narcissism in young adults.  While we need to acknowledge correlation does not mean causation, it is important to understand that there seems to be an influence of parenting and discipline upon the development of narcissism. 

There is often the question about trauma as a causal factor for personality disorders.  The factors that can cause NPD are varied; what appears to be consistent in the literature and conceptualization of narcissisim is understanding the narcissistic injury that was incurred by the child, which may or may not have been parental abuse or trauma in childhood.  According to van Schie et al., (2020), there was no direct effect of remembered maltreatment in childhood on young adult narcissism. 

DSM 5 TR Criteria for Narcissistic Personality Disorder

According to the DSM 5 TR (American Psychiatric Association, 2022), Narcissistic Personality Disorder is:

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).

2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

3. Believes that s/he is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).

4. Requires excessive admiration.

5. Has a sense of entitlement (e.g., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).

6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).

7. Lacks empathy; is unwilling to recognize or identify with the feelings and needs of others.

8. Is often envious of others or believes that others are envious of him or her.

9. Shows arrogant, haughty behaviors or attitudes.

It is important to understand that arrogance, in isolation, does not make a narcissist.  None of these behaviors can be seen in isolation; as a clinician, I am always paying attention to a pervasive pattern of behaviors.  So, we, too, should be curious about the behaviors of those we are in a relationship with.  Behaviors cannot be seen in isolation – we need to see the full picture.

The prevalence rate for Narcissistic Personality Disorder is relatively low, and there is little research being done in this realm in comparison to other clincial conditions (South et al., 2011).  The fact that individuals suffering from NPD, especially the grandiose type, tend to resist therapeutic intervention may be what contributes to the low documented prevalence rate.  According to the DSM 5 TR (American Psychiatric Association, 2022), the median prevalence of NPD is 1.6%, and there is a gender bias towards males.  However, women can suffer from NPD as well, and this prevalence rate is unknown.  

In our next issue brief, we will discuss the different types of narcissists in greater detail.