Is Narcissistic Personality Disorder a Mental Illness?

When narcissism runs out of control it can cause a slew of interpersonal and occupational difficulties, making happiness and success elusive.

There is no disputing the disruptive capacities of narcissistic personality traits. Narcissists suffer from an extreme self-centeredness, which leaves them incapable and uninterested in seeing things from anyone else’s perspective. They suffer from delusions of grandeur boosted by feelings of infallibility, yet they are also highly competitive and insecure. They respond to the success of others with anger and envy, and they feel mistreated and overlooked if others fail to praise and compliment them repeatedly.

Chronic narcissism often leads to a diagnosis of narcissistic personality disorder (NPD), one of 10 personality disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

At one time, personality disorders were not recognized as a form of mental illness. However, as psychiatrists and psychologists learned more about the specifics of these conditions, it became clear that personality disorders, including NPD, can be legitimately classified as mental health disorders.

Up to six percent of American adults suffer symptoms consistent with a diagnosis of narcissistic personality disorder. But many people who clearly don’t fit the NPD mold demonstrate at least some narcissistic tendencies, and many mental health experts argue that everyone is capable of narcissistic behavior from time to time.

In general, people with narcissistic tendencies are self-centered, boastfully self-confident, opinionated, ambitious, quick to anger at those who disagree with them, eager to associate only with “important” people, occasionally resentful of the success of others, and willing to lie if it serves their needs.

These traits are easy to spot in people who exhibit them frequently, and even if people aren’t aware of the existence of narcissistic personality disorder they would have little trouble identifying people who fit its profile. But many, if not most, people engage in some of the distinctive behaviors—or adopt the attitudes—of NPD from time to time, even if they don’t come close to meeting the criteria for the actual, full-blown disorder.

Some people believe that early 21st century culture as a whole is helping promote narcissistic attitudes, which may explain why young people have the highest rates of NPD and elderly people the lowest (9.4 percent of the age 20-29 population versus just 3.2 percent among those 65 and older meet the criteria for NPD). Narcissism seems to be more on display than ever before in politics, business, and entertainment, and even mental health professionals who normally avoid social or cultural criticism have noted the popularization of narcissistic behavior in the broader society.

For these reasons and more, it is common among psychiatrists to view NPD as a spectrum disorder, in acknowledgment of the fact that NPD sufferers exhibit an overabundance of symptoms that are relatively common but far less prevalent in most people.

People with NPD occupy one end of the narcissism spectrum; those who exhibit only the occasional narcissistic symptoms (and often feel guilty about it afterward) occupy the other; and those with a few consistent narcissistic traits are located somewhere in the middle.

Narcissistic personality disorder, along with the other personality disorders, was first listed as a mental health disorder in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III), which was published in 1980.

From 1980 to 2013, personality disorders were classified as Axis II mental health disorders, to separate them from other types of mental illness (anxiety disorders, mood disorders, schizophrenia, obsessive-compulsive disorder, etc.), which were grouped under the Axis I designation. The difference was that Axis II personality disorders were believed to be permanent mental conditions, while Axis I disorders were often temporary and transient in nature and might fade in intensity (or possibly disappear entirely) after a sustained period of treatment.

But eventually, as knowledge about the developmental dynamics of both Axis I and Axis II mental health disorders evolved, the supposed distinctions that separated them were no longer as clear.

For example, there is now plenty of evidence to show that personality disorders are treatable, and those who suffer from their symptoms can experience significant improvement. Personality disorders are not curable, but they don’t have to be permanent, unalterable conditions either. If those diagnosed with NPD are willing to dedicate time and energy to overcoming their narcissistic tendencies, they can change their lives for the better—and those changes can be sustainable.

With the issuance of the DSM-5 in 2013, the axis model for creating separate categories of mental health disorders was officially abandoned, along with certain assumptions about the permanency and root characteristics of uncontrolled narcissistic behavior.

But regardless of how personality disorders are conceived and identified, there is no longer any controversy about their status: all the personality disorders, including narcissistic personality disorder, are forms of mental illness that can and will respond to treatment, if it is properly administered and the patient is truly prepared to heal.

For narcissistic personality disorder specifically, the following characteristics help to identify it as a true mental health disorder:

• Environmental factors play a more decisive role in the development of NPD than genetic influences, by a three-to-one ratio. This means that no one is simply born with narcissistic personality disorder, and it may not have developed at all if the determining environmental factors had been different.
• Narcissistic personality disorder causes impaired functioning in both the occupational and interpersonal domains, which is a chief characteristic of mental health disorders.
• The symptoms of narcissistic personality disorder are emotional, psychological, and behavioral, making it a pervasive condition that negatively impacts every area of a sufferer’s life.
• People with NPD have a skewed and distorted picture of reality. They are incapable of perceiving themselves or the world as it really is, and their relationships with other people are undermined by the persistence of their illusions.
• Rather than an accurate reflection of their true feelings, the grandiose and egomaniacal claims and beliefs of the narcissist are actually a cover for deep-seated insecurity and self-esteem problems, which can inevitably be traced back to the dysfunctional family life they experienced as children. Traumatic childhood experiences are often decisive factors in the development of mental illness, and that is certainly the case with narcissistic personality disorder.
• The symptoms of narcissistic personality disorder do respond favorably to treatment. In one notable experiment, is was discovered that people diagnosed with NPD could learn to experience empathy, with the help of therapists trained to help narcissists alter their perspective. NPD sufferers are not supposed to feel empathy, but the fact that they can shows the symptoms of NPD are malleable and not set in stone.

Each of these characteristics is typical of mental health disorders, which have unfixed paths of development that are always amenable to change.

The DSM-5 identifies the essential features of any personality disorder as “impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits.”

In the case of narcissistic personality disorder, five out of these nine symptoms must be detected during the evaluation stage for NPD to be diagnosed:

• An inflated sense of self-importance, separate from any actual achievements or talent
• Preoccupation with fantasies of success, power, beauty, love, and recognition
• Desire to associate only with people of exalted (equal) status
• Need for constant flattery and reinforcement from others
• A sense of entitlement, accompanied by petulant behavior in the face of refusal to cooperate
• Exploitive and manipulative behavior
• No apparent capacity for empathy
• Tendency to be envious and to believe others are the same
• Arrogant, presumptuous attitudes and behaviors

The only way mental health professionals can make a diagnosis for NPD is if sufferers willingly to submit to an interview and fill out the appropriate questionnaires.

There is no doubt narcissistic personality disorder responds favorably to treatment. This is the case when its symptoms are treated individually, or as part of an integrated treatment program for NPD sufferers battling additional emotional or behavioral health disorder (more than half of all adults with NPD also have co-occurring mental health disorders).

The one problem is that many NPD sufferers are too driven by ego to admit to weakness, and they see therapy as just such an admission. They insist on blaming other people for their failing relationships, checkered work history, and failure to live up to their immense (in their eyes) potential, and under no circumstances will they accept any responsibility for their own troubles.

Breaking through the barriers that NPD sufferers erect to protect themselves from the truth is difficult in any circumstance. But the chances for success are improved if sufferers agree to participate in an inpatient NPD treatment program in a residential mental health facility.

Intensive, focused, inpatient therapy (individual, group, and family) in the initial stages of recovery can help NPD sufferers overcome their strongest denials and inhibitions, while helping them identify the situations and people that trigger their most self-destructive and unproductive thoughts and behavior. NPD sufferers must reprogram their minds if they expect to get better, and that is far easier to do in a residential setting where all outside distractions are eliminated.

Personality disorders are enduring, but they are not a prison that offers no possibility of escape. Narcissists who seek and accept professional assistance have a real opportunity to improve their lives and heal the breaches they’ve created with the most important people in their lives.