If you want to write an article that gets read by thousands of people, be sure to include some variant of "narcissism" in the title. It seems there is a great hunger for info on narcissistic personality disorder (NPD) — what it is, how to identify it, how to co-exist with someone who exhibits NPD, or how to go on after having been in a relationship with a narcissist.

This great interest is curious, given that NPD is a relatively rare condition — at least it is one encountered only infrequently in clinical settings. The highest prevalence rates reported run around 6-7% for men and 4-5% for women. But people with NPD are not known for seeking help from mental health clinicians. In fact, if a patient were to tell me that they were worried that they might have narcissistic personality disorder, I could be fairly certain that they don't — narcissists don't worry about being narcissists. To do so would imply the presence of empathy: "I worry about being a narcissist because being a narcissist would mean that I am harming or exploiting others and I wouldn't want to do that." This is logic that does not compute for someone with a true case of NPD.

People with NPD are most likely to "come to clinical attention" in the context of treatment for some other mental disorder, usually a mood disorder or a substance use disorder. Comorbidity with alcohol dependence is around 13%, and clinical lore also associates NPD with cocaine use. In my clinical practice, people with NPD usually present with a depressive reaction after some setback or loss: a rejection from medical school; failure to secure a sought-after promotion; the withdrawal of support from financial backers on a business venture; a spouse leaving them.

Treatment is usually short-term: Remind them of their many strengths and past accomplishments, show them some positive regard (even admiration), and their narcissistic defenses are quickly restored, their mood symptoms resolve, and suddenly they wonder why they have been wasting their time talking with a relative nobody like me. In a few cases, I have convinced patients with NPD to engage in longer-term therapy in order to prevent future depressive reactions or to address their substance misuse, but it is not often their preference.

NPD is a severe personality disorder, and it shares characteristics with another severe personality disorder, antisocial personality disorder (ASPD). Both NPD and ASPD are marked by empathy deficits: Not only do these individuals not concern themselves with other people's rights or feelings, they cannot seem to imagine what other people might be feeling or thinking. I once watched a medical student interview a man with both ASPD and NPD who had been arrested for beating his girlfriend. She asked him how he thought the girlfriend felt while she was being assaulted. "How should I know what she's feeling? Angry, probably." The best he could come up with was what he had been feeling (or at least, the "screen emotion" that he perceived himself to be feeling — in his case I suspect that shame was the emotion that sparked the anger, which fueled the violence).

If you can't conceive of other people as fully formed human beings with inner lives as vivid as (or even richer than) your own, it becomes far easier to use them as means to your own ends — that is, to exploit them.

It is essential to remember that NPD is a "disorder" — its presence results in dysfunction across contexts. There are pervasive negative consequences of exhibiting NPD: occupational, social, health, legal, etc. It is rarely the case that someone with NPD is generally well-liked, professionally successful, and healthy, but saves all his pathology for his primary intimate relationship. People with NPD have a serious mental disorder and they deserve care and treatment.

On the other hand, there are many, many more people who are simply selfish and mean than there are people who have NPD. This is an important distinction. If your ex-spouse was selfish and mean, it's okay to describe them that way and to not go reaching for a psychiatric explanation for their behavior. I wonder if our society has become so terrified of making value judgments that we resort to "value-free" psychiatric diagnosis instead. We won't dare say that Mozart is musically superior to Taylor Swift because "that's just a matter of opinion" as opposed to an objective statement of truth. We won't say that our exes are "selfish and mean" because that sounds like a value judgment, so instead we say they have NPD: "I'm not judging; they just meet all the diagnostic criteria I found online."

There's a saying in psychiatric diagnosis: "If you hear hoofbeats, think horses, not zebras." People who are selfish and mean are common, like horses. People with NPD are relatively rare, like zebras. There's a reason why Taylor Swift wrote, "Why you gotta be so mean?" and not "Why do you have Narcissistic Personality Disorder?"

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