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Narcissistic Personality Disorder

(F60.81) Diagnostic Criteria

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 he or she 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 (i.e., 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.

Diagnostic Features

The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for
admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts.

Individuals with this disorder have a grandiose sense of self-importance, which may be manifest as an
exaggerated or unrealistic sense of superiority, value, or capability (Criterion 1). They tend to overestimate their

abilities and amplify their accomplishments, often appearing boastful and pretentious. They may blithely
assume that others attribute the same value to their efforts and may be surprised when the praise they expect
and feel they deserve is not forthcoming. Often implicit in the inflated judgments of their own
accomplishments is an underestimation or devaluation of the contributions of others. Individuals with
narcissistic personality disorder are often preoccupied with fantasies of unlimited success, power, brilliance,

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beauty, or ideal love (Criterion 2). They may ruminate about “long overdue” admiration and privilege and
compare themselves favorably with famous or privileged people.

Individuals with narcissistic personality disorder believe that they are special or unique and expect others to
recognize them as such (Criterion 3). They can be surprised or even devastated when the recognition of acclaim
they expect and feel they deserve from others is not forthcoming. They may feel that they can only be
understood by, and should only associate with, people of high status and may attribute “unique,” “perfect,” or
“gifted” qualities to those with whom they associate. Individuals with this disorder believe that their needs are

special and beyond the ken of ordinary people. Their own self-esteem is enhanced (i.e., “mirrored”) by the
idealized value that they assign to those with whom they associate. They are likely to insist on having only the
“top” person (doctor, lawyer, hairdresser, instructor) or being affiliated with the “best” institutions but may
devalue the credentials of those who disappoint them.

Individuals with this disorder generally require excessive admiration (Criterion 4). Their self-esteem is almost
invariably very fragile, and their struggle with severe internal self-doubt, self-criticism, and emptiness results in
their need to actively seek others’ admiration. They may be preoccupied with how well they are doing and how
favorably they are regarded by others. They may expect their arrival to be greeted with great fanfare and are

astonished if others do not covet their possessions. They may constantly fish for compliments, often with great
charm.

A sense of entitlement, which is rooted in their distorted sense of self-worth, is evident in these individuals’
unreasonable expectation of especially favorable treatment (Criterion 5). They expect to be catered to and are
puzzled or furious when this does not happen. For example, they may assume that they do not have to wait in
line and that their priorities are so important that others should defer to them, and then get irritated when
others fail to assist “in their very important work.” They expect to be given whatever they want or feel they

need, no matter what it might mean to others. For example, these individuals may expect great dedication from
others and may overwork them without regard for the impact on their lives. This sense of entitlement,
combined with a lack of understanding and sensitivity to the wants and needs of others, may result in the
conscious or unwitting exploitation of others (Criterion 6). They tend to form friendships or romantic
relationships only if the other person seems likely to advance their purposes or otherwise enhance their self-
esteem. They often usurp special privileges and extra resources that they believe they deserve. Some

individuals with narcissistic personality disorder intentionally and purposefully take advantage of others
emotionally, socially, intellectually, or financially for their own purposes and gains.

Individuals with narcissistic personality disorder generally have a lack of empathy and are unwilling to
recognize or identify with the desires, subjective experiences, and feelings of others (Criterion 7). They tend to
have some degree of cognitive empathy (understanding another person’s perspective on an intellectual level)
but lack emotional empathy (directly feeling the emotions that another person is feeling) (Ritter et al. 2011).
These individuals may be oblivious to the hurt their remarks may inflict (e.g., exuberantly telling a former lover
that “I am now in the relationship of a lifetime!”; boasting of health in front of someone who is sick). When

recognized, the needs, desires, or feelings of others are likely to be viewed disparagingly as signs of weakness
or vulnerability. Those who relate to individuals with narcissistic personality disorder typically find an emotional
coldness and lack of reciprocal interest.

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These individuals are often envious of others or believe that others are envious of them (Criterion 8). They may
begrudge others their successes or possessions, feeling that they better deserve those achievements,

admiration, or privileges. They may harshly devalue the contributions of others, particularly when those
individuals have received acknowledgment or praise for their accomplishments. Arrogant, haughty behaviors
characterize these individuals; they often display snobbish, disdainful, or patronizing attitudes (Criterion 9).

Associated Features

Vulnerability in self-esteem makes individuals with narcissistic personality disorder very sensitive to criticism or
defeat. Although they may not show it outwardly, such experiences may leave them feeling ashamed,
humiliated, degraded, hollow, and empty. They may react with disdain, rage, or defiant counterattack. However,

such experiences can also lead to social withdrawal or an appearance of humility that may mask and protect
the grandiosity. Interpersonal relations are typically impaired because of problems related to self-
preoccupation, entitlement, need for admiration, and relative disregard for the sensitivities of others.

Individuals with narcissistic personality disorder can be competent and high functioning with professional and
social success, while others can have various levels of functional impairment. Professional capability combined
with self-control, stoicism, and interpersonal distancing with minimal self-disclosure can support sustained life
engagement and even enable marriage and social affiliations. Sometimes ambition and temporary confidence
lead to high achievements, but performance can be disrupted because of fluctuating self-confidence and

intolerance of criticism or defeat. Some individuals with narcissistic personality disorder have very low
vocational functioning, reflecting an unwillingness to take a risk in competitive or other situations in which
failure or defeat can be possible.

Low self-esteem with inferiority, vulnerability, and sustained feelings of shame, envy, and humiliation
accompanied by self-criticism and insecurity can make individuals with narcissistic personality disorder
susceptible to social withdrawal, emptiness, and depressed mood. High perfectionist standards are often
associated with significant fear of exposure to imperfection, failure, and overwhelming emotions (Ronningstam
and Baskin-Sommers 2013).

Prevalence

The estimated prevalence of narcissistic personality disorder based on a probability subsample from Part II of

the National Comorbidity Survey Replication was 0.0% (Lenzenweger et al. 2007).The prevalence of narcissistic
personality disorder in the National Epidemiologic Survey on Alcohol and Related Conditions data was 6.2%
(Stinson et al. 2008). A review of five epidemiological studies (four in the United States) found a median
prevalence of 1.6% (Morgan and Zimmerman 2018).

Development and Course

Narcissistic traits may be particularly common in adolescents but do not necessarily indicate that the individual
will develop narcissistic personality disorder in adulthood. Predominant narcissistic traits or manifestations of
the full disorder may first come to clinical attention or be exacerbated in the context of unexpected or

extremely challenging life experiences or crises, such as bankruptcies, demotions or loss of work, or divorces. In
addition, individuals with narcissistic personality disorder may have specific difficulties adjusting to the onset of
physical and occupational limitations that are inherent in the aging process. However, life experiences, such as
new durable relationships, real successful achievements, and tolerable disappointments and setbacks, can all be

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corrective and contribute to changes and improvements in individuals with this disorder (Ronningstam et al.
1995).

Culture-Related Diagnostic Issues

Narcissistic traits may be elevated in sociocultural contexts that emphasize individualism and personal
autonomy over collectivistic goals (Cai et al. 2012; Meisel et al. 2016; Miller et al. 2015; Vater et al. 2018).
Compared with collectivistic contexts, in individualistic contexts, narcissistic traits may warrant less clinical
attention or less frequently lead to social impairment.

Sex- and Gender-Related Diagnostic Issues

Among adults age 18 and older diagnosed with narcissistic personality disorder, 50%–75% are men (Grijalva et

al. 2015). Gender differences in adults with this disorder include stronger reactivity in response to stress and
compromised empathic processing in men as opposed to self-focus and withdrawal in women (Hoertel et al.
2018). Culturally based gender patterns and expectations may also contribute to gender differences in
narcissistic personality disorder traits and patterns.

Association With Suicidal Thoughts or Behavior

In the context of severe stress, and given the perfectionism often associated with narcissistic personality
disorder, exposure to imperfection, failure, and overwhelming emotions can evoke suicidal ideation (Blasco-

Fontecilla et al. 2009; Ronningstam 2018; Ronningstam and Baskin-Sommers 2013). Suicide attempts in
individuals with narcissistic personality disorder tend to be less impulsive and are characterized by higher
lethality compared with suicide attempts by individuals with other personality disorders (Blasco-Fontecilla et al.
2009).

Differential Diagnosis
Other personality disorders and personality traits

Other personality disorders may be confused with narcissistic personality disorder because they have certain
features in common. It is, therefore, important to distinguish among these disorders based on differences in

their characteristic features. However, if an individual has personality features that meet criteria for one or more
personality disorders in addition to narcissistic personality disorder, all can be diagnosed. The most useful
feature in discriminating narcissistic personality disorder from histrionic, antisocial, and borderline personality
disorders, in which the interactive styles are coquettish, callous, and needy, respectively, is the grandiosity
characteristic of narcissistic personality disorder. The relative stability of self-image and self-control as well as
the relative lack of self-destructiveness, impulsivity, separation insecurity, and emotional hyperreactivity also

help distinguish narcissistic personality disorder from borderline personality disorder (Fossati et al. 2016).

Excessive pride in achievements, a relative lack of emotional display, and ignorance of or disdain for others’

sensitivities help distinguish narcissistic personality disorder from histrionic personality disorder. Although
individuals with borderline, histrionic, and narcissistic personality disorders may require much attention, those
with narcissistic personality disorder specifically need that attention to be admiring. Individuals with antisocial
and narcissistic personality disorders share a tendency to be tough-minded, glib, superficial, exploitative, and
unempathic. However, narcissistic personality disorder does not necessarily include characteristics of impulsive
aggressivity and deceitfulness. In addition, individuals with antisocial personality disorder may be more

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indifferent and less sensitive to others’ reactions or criticism, and individuals with narcissistic personality
disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood.

In both narcissistic personality disorder and obsessive-compulsive personality disorder, the individual may
profess a commitment to perfectionism and believe that others cannot do things as well. However, while those

with obsessive-compulsive personality disorder tend to be more immersed in perfectionism related to order
and rigidity, individuals with narcissistic personality disorder tend to set high perfectionistic standards,
especially for appearance and performance, and to be critically concerned if they are not measuring up (Smith
et al. 2016).

Suspiciousness and social withdrawal usually distinguish those with schizotypal, avoidant, or paranoid
personality disorder from those with narcissistic personality disorder. When these qualities are present in
individuals with narcissistic personality disorder, they derive primarily from shame and fear of failure, or fear of
having imperfections or flaws revealed.

Many highly successful individuals display personality traits that might be considered narcissistic. Only when
these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective

distress do they constitute narcissistic personality disorder.

Mania or hypomania

Grandiosity may emerge as part of manic or hypomanic episodes, but the association with mood change or

functional impairments helps distinguish these episodes from narcissistic personality disorder.

Substance use disorders

Narcissistic personality disorder must also be distinguished from symptoms that may develop in association

with persistent substance use.

Persistent depressive disorder

Experiences that threaten self-esteem can evoke a deep sense of inferiority and sustained feelings of shame,
envy, self-criticism, and insecurity in individuals with narcissistic personality disorder that can result in
persistent negative feelings resembling those seen in persistent depressive disorder (Tritt et al. 2010). If criteria
are also met for persistent depressive disorder, both conditions can be diagnosed.

Comorbidity

Narcissistic personality disorder is associated with depressive disorders (persistent depressive disorder and
major depressive disorder), anorexia nervosa, and substance use disorders (especially related to cocaine).
Histrionic, borderline, antisocial, and paranoid personality disorders may also be associated with narcissistic

personality disorder.

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Cluster C Personality Disorders

Avoidant Personality Disorder

(F60.6) Diagnostic Criteria

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to

negative evaluation, beginning by early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:

1. Avoids occupational activities that involve significant interpersonal contact because of

fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being shamed or
ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to engage in any new activities because
they may prove embarrassing.

Diagnostic Features

The essential feature of avoidant personality disorder is a pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluation that begins by early adulthood and is present in a
variety of contexts.

Individuals with avoidant personality disorder avoid work activities that involve significant interpersonal contact
because of fears of criticism, disapproval, or rejection (Criterion 1). Offers of job promotions may be declined
because failure to manage the new responsibilities might result in criticism from coworkers. These individuals

avoid making new friends unless they are certain they will be liked and accepted without criticism (Criterion 2).
Until they pass stringent tests proving the contrary, other people are assumed to be critical and disapproving.
Individuals with this disorder are highly avoidant of group activities. Interpersonal intimacy is often difficult for
these individuals, although they are able to establish intimate relationships when there is assurance of uncritical
acceptance. They may act with restraint, be reluctant to talk about themselves, and withhold intimate feelings

for fear of being exposed, ridiculed, or shamed (Criterion 3).

Because individuals with this disorder are preoccupied with being criticized or rejected in social situations, they
may have a markedly low threshold for detecting such reactions (Criterion 4). If someone is even slightly

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disapproving or critical, they may feel extremely hurt. They tend to be shy, quiet, inhibited, and “invisible”
because of the fear that any attention would be critical or rejecting. They expect that no matter what they say,
others will see it as “wrong,” and so they may say nothing at all. They react strongly to subtle cues that are
suggestive of mockery or derision, and may misinterpret a neutral gesture or statement as critical or rejecting.
Despite their longing to be active participants in social life, they fear placing their psychological welfare in the

hands of others. Individuals with avoidant personality disorder are inhibited in new interpersonal situations
because they feel inadequate and have low self-esteem (Criterion 5). These individuals believe themselves to be
socially inept, personally unappealing, or inferior to others (Criterion 6). Doubts concerning social competence
and personal appeal may be most intense for some individuals in settings involving interactions with strangers.
But many others report more difficulties with repeated interaction, when sharing of personal information would

normally occur, thus, in the individual’s perception, increasing the chances that their inferiority would be
revealed and that they would be rejected. When commencing a new ongoing social or occupational
commitment requiring repeated interpersonal interaction, individuals may over weeks or months develop a
growing conviction that others or colleagues view them as inferior or lacking worth, resulting in intolerable
distress or anxiety that prompts resignation. Thus, a history of repeated job changes may be present.
Individuals with this disorder are unusually reluctant to take personal risks or to engage in any new activities

because these may prove embarrassing (Criterion 7). They are prone to exaggerate the potential dangers of
ordinary situations, and a restricted lifestyle may result from their need for certainty and security.

Associated Features

Individuals with avoidant personality disorder often vigilantly appraise the movements and expressions of
those with whom they come into contact. They are likely to misinterpret social responses as critical, which in
turn confirms their self-doubts. They are described by others as being “shy,” “timid,” “lonely,” and “isolated.”
The major problems associated with this disorder occur in social and occupational functioning. The low self-
esteem and hypersensitivity to rejection are associated with restricted interpersonal contacts. These individuals

may become relatively isolated and usually do not have a large social support network that can help them
weather crises. They desire affection and acceptance and may fantasize about idealized relationships with
others. Avoidant behaviors can also adversely affect occupational functioning because these individuals try to
avoid the types of social situations that may be important for meeting the basic demands of the job or for
advancement.

Individuals with avoidant personality disorder have been reported as having insecure attachment styles
characterized by a desire for emotional attachment (which may include a preoccupation with previous and
current relationships), but their fears that others may not value them or may hurt them may lead them to

respond with passivity, anger, or fear (MacDonald et al. 2013). These attachment patterns have been referred to
variously as “preoccupied” or “fearful” depending on the model employed by researchers.

Prevalence

The estimated prevalence of avoidant personality disorder based on a probability subsample from Part II of the
National Comorbidity Survey Replication was 5.2% (Lenzenweger et al. 2007). The prevalence of avoidant
personality disorder in the National Epidemiologic Survey on Alcohol and Related Conditions was 2.4% (Grant
et al. 2004). A review of six epidemiological studies (four in the United States) found a median prevalence of

2.1% (Morgan and Zimmerman 2018).

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Development and Course

The avoidant behavior often starts in infancy or childhood with shyness, isolation, and fear of strangers and

new situations. Although shyness in childhood is a common precursor of avoidant personality disorder, in most
individuals it tends to gradually dissipate as they get older. In contrast, individuals who go on to develop
avoidant personality disorder may become increasingly shy and avoidant during adolescence and early
adulthood, when social relationships with new people become especially important. There is some evidence
that in adults, avoidant personality disorder tends to become less evident or to remit with age; the prevalence

in adults older than 65 years has been estimated at 0.8% (Schuster et al. 2013). This diagnosis should be used
with great caution in children and adolescents, for whom shy and avoidant behavior may be developmentally
appropriate.

Culture-Related Diagnostic Issues

There may be variation in the degree to which different cultural and ethnic groups regard diffidence and
avoidance as appropriate. Moreover, avoidant behavior may be the result of problems in acculturation
following migration. In some sociocultural contexts, marked avoidance might occur following social
embarrassment (“loss of face”) or failure to meet major life goals rather than temperamental shyness (Koyama

et al. 2010; Teo et al. 2015). In these settings, the goal of avoidance includes deliberate minimization of social
interactions in order to preserve social harmony or prevent public offense.

Sex- and Gender-Related Diagnostic Issues

Avoidant personality disorder appears to be more common in women than in men in community surveys (Cox
et al. 2009; Furnham and Trickey 2011; Hasin and Grant 2015; Lampe and Sunderland 2015; Trull et al. 2010).
This gender difference in prevalence is small but consistently found in large population-based samples
(Furnham and Trickey 2011).

Differential Diagnosis
Social anxiety disorder

There appears to be a great deal of overlap between avoidant personality disorder and social anxiety disorder.

It has been suggested that they may represent different manifestations of similar underlying problems, or
avoidant personality disorder may be a more severe form of social anxiety disorder (Reich 2009). However,
differences have also been described, especially in relation to self-concept (such as self-esteem and the sense
of inferiority in avoidant personality disorder) (Dreessen et al. 1999; Eikenaes et al. 2013; Hummelen et al. 2007;
Lampe 2015; Weinbrecht et al. 2016; Wilson and Rapee 2006); the latter is indirect evidence as it shows that

negative self-concept in social anxiety disorder may be unstable and thus less pervasive and entrenched than in
avoidant personality disorder. Additionally, studies have shown that avoidant personality disorder frequently
occurs in the absence of social anxiety disorder (Friborg et al. 2013; Lampe and Malhi 2018), and some separate
risk factors have been identified (Torvik et al. 2016), providing support for retaining two separate diagnostic
categories.

Agoraphobia

Avoidance characterizes both avoidant personality disorder and agoraphobia, and they often co-occur. They
can be distinguished by the motivation for the avoidance (e.g., fear of panic or physical harm in agoraphobia).

Other personality disorders and personality traits

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Other personality disorders may be confused with avoidant personality disorder because they have certain
features in common. It is, therefore, important to distinguish among these disorders based on differences in
their characteristic features. However, if an individual has personality features that meet criteria for one or more
personality disorders in addition to avoidant personality disorder, all can be diagnosed. Both avoidant
personality disorder and dependent personality disorder are characterized by feelings of inadequacy,

hypersensitivity to criticism, and a need for reassurance. Similar behaviors (e.g., unassertiveness) and attributes
(e.g., low self-esteem and low self-confidence) may be observed in both dependent personality disorder and
avoidant personality disorder, although other behaviors are notably divergent, such as avoidance of social
proximity in avoidant personality disorder but proximity-seeking in dependent personality disorder. The
motivations behind similar behaviors may be quite different. For example, the unassertiveness in avoidant

personality disorder is described as more closely related to fears of being rejected or humiliated, whereas in
dependent personality disorder it is motivated by the desire to avoid being left to fend for oneself (Beck et al.
2014; Horowitz and Wilson 2005; Lampe and Malhi 2018). However, avoidant personality disorder and
dependent personality disorder may be particularly likely to co-occur. Like avoidant personality disorder,
schizoid personality disorder and schizotypal personality disorder are characterized by social isolation.
However, individuals with avoidant personality disorder want to have relationships with others and feel their

loneliness deeply, whereas those with schizoid or schizotypal personality disorder may be content with and
even prefer their social isolation. Paranoid personality disorder and avoidant personality disorder are both
characterized by a reluctance to confide in others. However, in avoidant personality disorder, this reluctance is
attributable more to a fear of humiliation or being found inadequate than to a fear of others’ malicious intent.

Many individuals display avoidant personality traits. Only when these traits are inflexible, maladaptive, and
persisting and cause significant functional impairment or subjective distress do they constitute avoidant
personality disorder.

Personality change due to another medical condition

Avoidant personality disorder must be distinguished from personality change due to another medical
condition, in which the traits that emerge are a direct physiological consequence of another medical condition.

Substance use disorders

Avoidant personality disorder must also be distinguished from symptoms that may develop in association with
persistent substance use.

Comorbidity

Other disorders that are commonly diagnosed with avoidant personality disorder include depressive disorders
and anxiety disorders, especially social anxiety disorder. Avoidant personality disorder also tends to be

diagnosed with schizoid personality disorder. Avoidant personality disorder is associated with increased rates
of substance use disorders at a similar rate to the generalized form of social anxiety disorder.

References

Beck AT, Davis DD, Freeman A: Cognitive Therapy of Personality Disorders, 3rd Edition. New York, Guilford, 2014

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Cox BJ, Pagura J, Stein MB, Sareen J: The relationship between generalized social phobia and avoidant personality disorder in a national
mental health survey. Depress Anxiety 26(4):354–362, 2009

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