Patients with narcissistic personality disorder (NPD) often present to the healthcare professional after hitting “rock bottom” in their careers or personal lives or at the strong urging of a family member who insists that they get professional help for their behavior.

Because NPD, by its nature, involves a haughty disregard for others and an insistence on one’s own innate superiority, narcissistic patients are unlikely to recognize their need for treatment and even less likely to seek help of their own accord. For this reason, patients with a diagnosis of NPD alone (ie, with no concomitant axis I diagnoses) make up a very small percentage of the total patient population seen by mental health professionals.

To be diagnosed with NPD, a patient must demonstrate a consistent and long-standing pattern of maladaptive behavior, starting in adolescence or early adulthood, that exemplifies 5 or more of the 9 criteria listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). [1] (See Overview.) Although many people display these criteria to some degree, NPD is diagnosed only when the symptoms are pervasive, debilitating, and socially and personally destructive.

Patients with NPD are also acutely sensitive to rejection or criticism and may avoid people or situations where there is the possibility of feeling “less than.” When criticized, such patients may become furious and lash out or withdraw into a shell of sullen hate. At their core, both of these reactions are thought to be due to intrinsically low self-esteem or a feeling of inferiority. [1]