Narcissistic personality disorder (NPD) remains a somewhat controversial diagnosis in the DSM-5. There are concerns about whether the diagnostic criteria used to define the disorder fully capture the nature of the condition and instead unduly stigmatize aspects of it. Some of the terms that define that condition highlight aspects such as “antagonism” and “lack of empathy” which, even if present, may characterize the condition as potentially morally culpable and unsympathetic. But research lately has attempted to focus on subtypes within NPD that may help both clinicians and laypeople understand the variability of the condition and identify better ways to manage and treat it.
NPD involves a pervasive and persistent pattern of self-importance and grandiosity, with a constant need for admiration from others and a need to surround oneself with others who are perceived as powerful and special. The condition has a wide range of functional severity associated with it, adding to the confusion about whether its definition accurately captures those who truly meet the criteria for a psychiatric disorder. NPD is considered one of the more difficult conditions to treat, because, by definition, individuals with it struggle to engage with external viewpoints and engage in self-reflection—although given the range of symptomatology and severity, it is certainly still possible to do so.
Two review articles in the American Journal of Psychiatry (Russ et al, 2008; Caligor et al, 2015) note that NPD may be a heterogeneous category that encompasses three major subtypes, with varying degrees of clinical severity and prognosis.
1. Grandiose “Overt” Type
This type is considered to have the highest severity of poor interpersonal and psychosocial functioning, and higher comorbidity with other psychiatric disorders (including other personality disorders and substance abuse). They may present with more anger and hostility than the other types. Despite more illness severity, people with this type of NPD are less likely to present for help and engage in treatment. In some severe cases, individuals with this presentation may encompass the “malignant narcissist” subtype.
2. Fragile/Vulnerable “Covert” Type
This type is considered to possibly present more often for mental health treatment, with higher comorbidity with depressive and anxiety disorders. These individuals have more issues with vulnerability to criticism, and fluctuation between high and low self-esteem. NPD may actually be missed as a core source of their symptomatology, as they do not necessarily present with the overt grandiosity and lack of empathy as some with the disorder. But they still may have underlying traits of covert expectations of superiority or recognition and remain preoccupied mainly with their own sensitivity and perceived failures.
3. High-Functioning “Exhibitionist” Type
This type is less likely to have psychiatric comorbidity and may not necessarily meet the functional impairment criterion for NPD, except during periodic crises or unexpected failures (such as losing a job or undergoing a divorce). They appear to be outwardly successful and generally maintain their ego stability, but they still maintain an essential NPD personality structure; issues with entitlement and self-centeredness may lead to interpersonal issues and exploitative, unempathetic behaviors.
These three subtypes may also reflect a spectrum for the condition that leads to public controversies over whether certain public figures or even everyday coworkers meet the criteria for NPD versus everyday narcissistic traits. The high-functioning type for example probably should not be defined usually as official NPD for a given individual; they are better described as people who have narcissistic personality traits, as, by definition, they are “high-functioning.” DSM-5 disorders require significant functional impairment; these individuals may only meet criteria when they have a crisis leading to depression or other problems. But their personality-driven behaviors may still lead to problems that have downstream personal and societal effects, even if they do not necessarily meet the criteria for requiring active psychiatric treatment.
Even more confusing, there are cases of outwardly high-functioning people who probably still meet the criteria for the first grandiose subtype, and even cross over into the “malignant narcissist” type, who also contain characteristics of the arguably more serious antisocial personality disorder (ASPD) with components of sadism. This subtype is not defined as an official DSM-5 subcategory but has been written about for decades in psychological literature (first defined by Erich Fromm and Otto Kernberg in the 1960s) due to concerns over historical figures who have its most extreme characteristics: typically genocidal dictators such as Hitler or Stalin. On the surface, these people were morbidly successful, rising to power over entire nations. But the consequences of their behaviors and cults of personality altered the course of history, causing mass murder, world wars, and unspeakable human costs.
The dilemma in such definitions is that inevitably they affect and stigmatize people’s perception of NPD as having a moral dimension, or lack thereof. And it may color an entire spectrum of people who meet some criteria for the condition as such, even if that may not be the case at all for some. Indeed, sometimes NPD can contribute to mildly stung feelings at best, and actual serious physical and emotional harm to others at most through aspects of manipulativeness and impaired empathy.
But many with NPD have a genuine mental health disorder and can be suffering and unable to control their dysfunctional patterns of behavior. They can often have a core of self-loathing and emptiness that stems from childhood emotional pain, issues of emotional neglect or trauma in their upbringing, or possible genetically driven emotional processing deficits. These people can sometimes engage positively in treatment and learn the language of interpersonal relationships and empathy successfully.
Overall, additional research continues to be needed to better characterize the clinical spectrum of NPD and ways to more precisely define its broad presentation. Hopefully, looking at the subtypes of NPD may help people better understand its complex nature and how best to help individuals with NPD.
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Russ E, Shedler J, Bradley R, Westen D. Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes. Am J Psychiatry 2008; 165:1473-1481.
Caligor E, Levy KN, Yeomans FE. Narcissistic personality disorder: diagnostic and clinical challenges. Am J Psychiatry 2015; 172:415-423.