Narcissistic Personality Disorder Explained

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The false self - Mark Ettensohn, Psy.D., Sacramento TherapistNarcissistic Personality Disorder (NPD) has gotten a lot of bad press. If you or a loved one have been diagnosed with this disorder, you may have many questions about what it means, what to expect, and maybe even how to feel.

If you’ve done any reading about narcissism, you’ve probably come across words like “vain,” “entitled,” “arrogant,” or “grandiose.” While words like these dominate pop-culture articles on narcissism, most people only have half of the picture.

There is an interesting history surrounding this term that has led many (including some clinicians) to misunderstand what narcissism really is.

In the 1980s, the American Psychiatric Association (APA) revised its diagnostic manual (DSM-III-R) in an attempt to make it less theoretically biased. Following this revision, the new diagnostic criteria for NPD were streamlined to focus entirely on the overt, grandiose features with which the term has become synonymous. People came to believe that NPD was all about vanity and entitlement, which led to a stigmatization of the disorder. Today, the word narcissist is often used as an insult.

However, the kind of narcissism presented in the media is only half the picture. In fact, many people with NPD struggle with low self-esteem, feelings of shame, alienation, chronic depression, and anxiety.

The vulnerable side of narcissism

There is a substantial body of literature (for a review, see Ettensohn, 2010) suggesting that there are actually two faces of NPD. The one we are all familiar with is called overt or grandiose narcissism. The less recognized one is called covert or vulnerable narcissism.

An easy way to think about this is to imagine the old horseshoe shaped magnets with which we are all familiar. The north and south poles have different properties that are based on the underlying principles of magnetism. It would be inaccurate to say that the two poles are different magnets entirely. They are different parts of the same magnet. Similarly, Grandiose and Vulnerable Narcissism are different poles of an underlying principle called core narcissistic conflict.

Okay, so what is core narcissistic conflict?

Core narcissistic conflict is actually a complicated idea. To really simplify things, people who struggle with core narcissistic conflict have trouble connecting with their authentic self. The authentic self is that place inside each of us that is the wellspring of vitality, sincerity, sorrow, and joy. People who are disconnected from this authentic self may report that they don’t know who they really are, or what they really want. They may have difficulty describing what makes them happy, what they really value, or how they really feel. Often, they have very little sense of their intrinsic value as a person.

Core narcissistic conflict causes a person to feel like they aren’t deserving of love unless they are good enough. They try to become good enough by hiding their real feelings (even from themselves) and substituting a false self in place of their authentic self.

The false self

A false self is a clinical term for a mask that someone wears – a persona that they adopt because it’s what they think other people want them to be. They may even be so used to it that they have come to believe it is who they really are.

The false self is all about being good enough. Unlike authentic self experience (which is intrinsically validating), the false self requires outside validation. People who have adopted a false self depend on being perceived as beautiful, talented, successful, funny, smart, or accomplished. The problem is that none of these attributes have anything to do with a real person. They describe what a person can do, not who a person is on the inside.

The tragedy of core narcissistic conflict is that the person feels he or she is only lovable when they are wearing the mask of the false self. The underlying authentic self goes unnoticed, and the person’s needs for care and acceptance get neglected. At the center of the person there is a never-ending need for love that never gets met. As you can imagine, this is a recipe for emotional suffering.

When the false self breaks down

The false self is a defensive facade. The person uses it because he or she believes it’s who they are supposed to be. They believe the false self protects them from rejection and abandonment. But the price for feeling protected is that the person gets stuck in a never-ending cycle of approval-seeking.

Like any defense, sometimes the false self gets weakened, leaving the person exposed to the underlying fears about not being good enough. The person may feel ashamed, depressed, worthless, anxious, panicked, or experience intense worries about death or sickness (hypochondria). This is vulnerable narcissism – the other pole of the magnet. Many people with NPD seek therapy in this state of emotional distress, and many clinicians who are not trained to recognize core narcissistic conflict will simply diagnose the person with dysthymia, major depression, or generalized anxiety disorder.

Different configurations of NPD

People with NPD can fluctuate between the grandiose and vulnerable poles of the magnet. To use a different metaphor, it’s sort of like a radio dial with “very vulnerable” at one end and “very defended” at the other end. A person can be anywhere in between. While some people spend most of their time in the defended position, others spend most of their time in the vulnerable position.

When a person’s false self defenses are working well, he or she is often unconscious of the underlying vulnerability. That doesn’t mean it is gone…it’s just hidden by the defenses. Entitlement hides a feeling of deep impoverishment, confidence hides a feeling of worthlessness, vanity hides a feeling of being undesirable, and charm hides a feeling of despair. Just as the sense of superiority is fueled by the need to avoid feeling worthless, the feeling of worthlessness is fueled by the sense that one should be superior. Unrealistic standards underlie both the grandiose and vulnerable aspects of NPD.

How is NPD treated?

The only effective treatment for NPD is therapy. Because it is a personality disorder (meaning it has to do with the basic ways a person relates to self and others), treatment takes time. It may take a year or more to notice lasting improvement.

What will treatment be like?

NPD is treated by addressing the underlying core narcissistic conflict. The person must be helped to recognize the false self as something that actually keeps them stuck in a never-ending pursuit of self-worth. They must also be helped to work through the vulnerability that emerges when their defenses break down. It can be a difficult process. But with time and a therapist trained to help the person connect with their authentic feelings, the false self defenses gradually diminish. As the person becomes more connected to their intrinsic worth as a person, they rely less on those around them for self-esteem maintenance.

Don’t be discouraged!

With treatment, many people with NPD are able to develop a more stable sense of self-esteem. The most important thing is to stick with treatment! Recovery takes time. It is often a difficult and frustrating process, but well worth it when you consider the possibility of having more satisfactory and meaningful relationships with yourself and those you care about.

If you have further questions about NPD, talking with a therapist can help. If you would like to contact me with questions about treatment for NPD, I can be reached by telephone or through this contact form.

Works cited:
Ettensohn, M.D. (2010). The relational roots of narcissism: Exploring relationships between attachment style, acceptance by parents and peers, and measures of grandiose and vulnerable narcissism. (Doctoral dissertation). Retrieved from Dissertations & Theses: Full Text. (Publication No. AAT 3515488).

*For a more technical account of diagnostic issues surrounding NPD, see this article, published by Dr. Ettensohn in the monthly newsletter of the Sacramento Valley Psychological Association: Toward a Functional Understanding of Psychopathology: The DSM-IV-TR and Narcissistic Personality Disorder

Before the patient knows what will make him feel good, he must feel. When the narcissist truly begins to feel, among his first feelings will be that injury, that hurt, that humiliation, which drives the grandiose false self in its quest to prove self-worth.”

– Stephen Johnson


  1. Lori
    July 18, 2014

    I am happy to see that treatment involves therapy. What about medication?

  2. Dr. Ettensohn
    July 22, 2014

    Hi Lori,
    Good question. Most disorders that respond well to medication have a sizable biological component. Bipolar Disorder is a good example. In contrast, personality disorders tend to be psychologically driven. They have to do with the characteristic ways that a person views him/herself, engages in relationships, and negotiates experiences in the world. Medication may be used to target specific symptoms (e.g. SSRIs for depressive/anxiety symptoms), but most clinicians would consider medication inappropriate for treating the core issues involved in personality disorders.

  3. The Quandary of Psychological Diagnsosis | Mark Ettensohn, Psy.D.
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  4. Life in a Bind
    June 18, 2015


    I was just wondering what the key differences are between covert narcissism and borderline personality disorder, as some of the aspects sound very similar? Is it the case that the person with BPD might share aspects with the vulnerable side of narcissism but the grandiose side would be missing? Have there been cases of misdiagnosing covert narcissism as BPD?

    Many thanks!

    • Dr. Ettensohn
      June 19, 2015

      Great question, and a difficult one to answer. BPD is a widely recognized disorder with specific diagnostic criteria, whereas vulnerable narcissism has not (yet) been included as an official diagnosis in the DSM. However, it does have fairly robust research support. The simple fact is that there is considerable overlap between many personality disorders, especially those grouped together in what the DSM-IV called “Cluster B” (antisocial, histrionic, narcissistic, and borderline). To add to the complications, the term “borderline” was originally used to describe a structural distinction within an individual’s personality, rather than a personality “type” (which is how it is used today). A person functioning at the “borderline level” was considered to have disturbed relational capacities and to rely on reality distorting defense mechanisms (such as splitting and projection), but they generally maintained the ability to reality-test (i.e. they were not psychotic). Thus, they were on the borderline between psychosis and neurosis. Using that meaning of borderline, it is possible for any personality type to be functioning at the borderline level. But then the DSM changed the term borderline to mean a specific personality type rather than a level of functioning within the personality.

      All of this is a complicated way of saying that there is confusing terminology at play here.

      To answer your question, a few key differences between BPD and vulnerable narcissism are: people with BPD tend to act in ways that are physically and psychologically self-destructive. This is often to demonstrate deeply felt pain that can’t be articulated in any other way. People with BPD also tend to be very reactive to feelings of abandonment (which is where the well-known book I Hate You – Don’t Leave Me gets its name). People with vulnerable narcissism tend to be less self-destructive and more preoccupied with regaining an idealized experience of self (think Beast in Disney’s Beauty and the Beast, who kept a tattered image of himself as the handsome prince on his bedroom wall). Both can share issues with mood dysregulation, distress tolerance, and identity disturbance. Both often experience deep feelings of worthlessness and shame. I think it is entirely possible for a person to exhibit traits that are consistent with both borderline and narcissistic personality organizations.

      TL;DR: It is possible for a person to be both borderline and narcissistic. Generally speaking, Narcissism is about maintaining an idealized sense of self and BPD is more about maintaining a needed relationship with another person.

  5. La
    June 21, 2015

    Thanks for this article. You mention treatment. Seems like most train of thought has been that you cannot treat or manage NPD. Is it possible to manage? Also, does one – grandiose or vulnerable – have a better prognosis than the other. Further, if you have had psychological testing and were diagnosed in Axis II as having possible borderline and narcissist features does that mean you actually have the personality disorders? Thanks.

    • Dr. Ettensohn
      June 22, 2015

      Vulnerable narcissism is easier to treat because the person tends to be more in touch with underlying feelings of inadequacy, depression, and shame; whereas these issues are masked and externalized (projected onto others) by grandiose defenses. As for prognosis, both present difficult challenges that require long term therapy to work through.

      As for narcissism being impossible to treat and/or manage, I have not found that to be the case. However, I work mostly with the vulnerable type because they tend to seek treatment in far greater numbers than grandiose narcissists (who sometimes only come to therapy because they are forced to for some reason). A lot of grandiose narcissists and narcissists who also have an antisocial element to their personalities are encountered in correctional and forensic settings – and these types of patients are indeed very difficult to treat.

      To answer your last question, I prefer not to think about personality disorders as something that a person “has” like a physical disease. Sometimes, a person has problematic tendencies in their personality that cause difficulties for themselves and those around them, and when those personality issues are severe enough we call that a personality disorder. Personality disorders require longer term treatment because they tend to be “egosyntonic,” which means that the person often doesn’t see the problem that everyone around them can see. People with personality disorders are basically holding a faulty play book: over-relying on one or two main coping strategies, misinterpreting the intentions and feelings of those around them, and unable to tolerate thoughts and feelings of their own that feel threatening.

      These problematic personality patterns have been roughly categorized in the DSM (the diagnostic manual used by many psychologists in the US). But the system is far from perfect and there is significant overlap between personality disorders. Borderline and Narcissistic Personality Disorders are grouped together in the DSM because they (along with histrionic and antisocial personality disorders) are considered to share common traits. While it is technically possible for a person to be diagnosed with both Borderline and Narcissistic Personality Disorders, I think the labels are less meaningful than identifying, discussing, and working through the issues with which a person is struggling.

  6. Angel eyes
    June 24, 2015


    Thanks a lot for this article, as well as the recent update (I particularly like the “magnet” analogy). Your explanation of VNPD in particular is very helpful because there is so little out there for us laymen to read, and also which is at all meaningful.

    I do have a question. I understand that VNPD and BPD are similar, but how does gender factor into it? My husband has been diagnosed as VNPD with BPD features and the latter especially seems to manifest differently for males. I’ve recently read a book on male BPD which is helpful but I am wondering whether males with VNPD also manifest different traits.

    Finally, do you think it’s a good idea for spouses to periodically meet with their psychologist (assuming your spouse is fine with it)? That is, does family support tend to help or hurt?


  7. Neil
    September 25, 2015

    Hi – I have read a lot of information on this topic and I find your writing in this complex area very clear and informative. Unlike may other I think you portray some possibilities with realistic qualification rather than “writing off” . This may appeal to my desire to help and make better but hopefully not unrealistically. The decision to end a relationship or not when some change may be possible take a different dimension. I appreciate that this will be different for everyone and their circumstances especially if there is violence. with awareness of the condition it remains terribly annoying and frustrating, however it is possible to be an “observer” with a good level of self esteem and patience and at least consider encouraging treatment. I am talking about VN type of course as well.Cheers

  8. ohio detox
    November 23, 2015

    Thanks for finally writing about >What is Narcissistic Personality Disorder?
    | Mark Ettensohn, Psy.D. <Loved it!

  9. Aliza
    December 1, 2015

    Hi Dr. Ettensohn,

    I am writing a paper about Vulnerable Narcissism, particularly focusing on how it affects people’s use of social media. I would love to read your 2010 paper – “The relational roots of narcissism: Exploring relationships between attachment style, acceptance by parents and peers, and measures of grandiose and vulnerable narcissism,” but I cannot find the full text anywhere. Do you know where I can find it?


  10. Aliza
    December 3, 2015

    Found it- thanks!!

  11. NVC, how do I love thee? Let me count the ways. | Swimming in Deep Water
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    […] to base a theory on, but I find it interesting nonetheless. It seems that true narcissists, both overt and covert, are temperamentally unsuited to using NVC as it is intended. It may be that they cannot attain the […]

  12. Julie
    June 9, 2016


    I was wondering how you distinguish between an individual who is experiencing similar self-image issues due to years and years of depression from someone with vulnerable narcissism? Has the person with depression been improperly diagnosed? I often feel very disconnected from my authentic self and require outside validation. I fluctuate between idealizing and devaluating both myself and those closest to me. However, I don’t utilize, for lack of a better word, any of the defenses you named in your short article above (entitlement, over-confidence, vanity). If anything I am self-deprecating. I never talk about myself. I don’t post pictures of myself on facebook. But I certainly do not have stable self-esteem. Have I been misdiagnosed?

    • Dr. Ettensohn
      June 11, 2016

      Hi Julie – I wouldn’t be able to comment on the accuracy of your diagnosis, but I will say that it is very possible for a person to struggle with depression and/or anxiety while also having a narcissistic personality style. Chronic depression is actually associated with vulnerable narcissism, and many of the vulnerable narcissists with whom I have worked are self-deprecating. For vulnerable narcissists, the grandiose defenses of entitlement, vanity, etc., are unconscious. Consciously, the person may feel invisible, unworthy, or unloved. But these feelings derive from implicit (aka unconscious) expectations that are unrealistically high and impossible to live up to. If you have a therapist, it may be beneficial to explore this possibility.

  13. Marci
    January 4, 2017

    I am wondering how a persons relationship with her father would play into this? My partner had a horrible relationship w her father — he basically ignored her– and now they don’t speak at all, not even to her children. I have found she has a lot of feelings of anxiety in our relationship-she even sought out my ex to have a relationship w her to discuss me behind my back all while accusing me of cheating. Does her parental relationship have to do with her behavior? How can I tell if she is a narcissist?

    • Dr. Ettensohn
      January 7, 2017

      Attachment research shows us that early relationships with caregivers have tremendous impact on us throughout our lives – affecting everything from school performance to job satisfaction, relationship satisfaction, and…yes…adult mental health. I can’t comment on your specific situation. Have you considered couples therapy?

  14. Marci
    January 12, 2017


    Thank you so much for your response.
    We have tried it briefly but it was immediately after and I was not in a place to be open. I don’t think ill ever get over the betrayal. But I had been blaming myself for a long time and after reading about narcissism I thought she might fit the profile.

    Thank you for your help!

  15. Elka
    January 21, 2017

    Fascinating. Thank you very much for this informative article. Narcissism has been mentioned in several reports on my mental health and I have always found that baffling because all my life I’ve struggled with feelings of inadequacy. Your article seems to explain that: I dinf myself in your description of the Vulnerable Narcissist. My question is: can Vulnerable Narcissism lay the ground for the development and “flourishing” of psychosomatic illness? You suggest that there is link between NPD and hypochondria. Can you please elaborate on that? And can you explain to me how (and why?) a Narcissistic person might develop and subconsciously nurture a physical illness?

    • Dr. Ettensohn
      January 22, 2017

      I’m happy you found the article helpful. Many people are confused by the idea that feelings of inadequacy underlie narcissistic issues. As for the somatic piece, vulnerable narcissism has been associated with chronic anxiety and depression, both of which often have somatic components. A more in-depth explanation (and one with much more conjecture) has to do with the idea of a fragmenting self. Ernest Wolf, a psychiatrist who collaborated closely with Heinz Kohut (the founder of Self Psychology), said this, “Metaphorically, we think of the self as a structure….Like all structures, we can think of the self as made of parts that either fit well together…as if well-glued, or can fall apart easily….we speak sometimes of a self that is cohesive, which means put together well, and at other times, of a self that is fragile and easily fragments.” Your ‘self’ is the system of thoughts and feelings you have about being you. For some, the self is a relatively stable and positive construct that provides a rewarding positive feedback loop between external and internal experiences. For others (including, it is thought, those with narcissistic issues), the self is more fragile – sensitive to criticism and prone to fragmentation. Fragmented self states cause anxiety, depression, frustration, paranoia, and other unpleasant experiences…including worries that the body itself is falling apart. Sometimes, these worries become obsessive, at which point we would call it hypochondriasis (now called illness anxiety disorder). Over time, such worries easily turn into actual physical illness due to the effects of chronic stress. Some common somatic components of chronic stress, worry, and depression include: digestive issues, chronic pain, back and neck issues, issues with cardiovascular health, problems with sexual performance and responsiveness, compromised immune system, and short term memory loss. This is by no means an exhaustive list. Primary care physicians are well acquainted with stress and anxiety related issues.

      If you are experiencing psychosomatic illness, regular self-care is vitally important. Take walks, get exercise, find time and space to relax. Another very effective method is mindfulness meditation. I wrote a post about it here.

  16. ZA
    February 20, 2017

    Hi – thanks for this article! I really identify with your description of vulnerable narcissism. But most people I know, at least to some extent, try to be perceived as smart, attractive, etc., and they present at least somewhat of a false self on social media. So my question is, is some degree of narcissism normal? And if so, at what point does it become a disorder? I’m asking because when I read about personality disorders I inevitably begin to worry that I have them, because I do often identify with the behavior/thinking. But there’s also a part of me that’s wondering if I might be overthinking perfectly normal behavior that only becomes problematic when taken to an extreme.

    • Dr. Ettensohn
      February 20, 2017

      Like all personality traits, narcissism exists on a spectrum from healthy functioning to severely disordered. Some degree of narcissism is not only normal… it’s necessary for healthy, adaptive functioning. We all get a bit puffed up from time to time, and we all want to make a good impression. Most people devote at least some of their mental and emotional resources to managing self-esteem and coping with self-esteem injuries. Narcissism becomes problematic when the majority of a person’s resources are devoted to propping up fragile self-esteem and compensating for injuries so slight that most wouldn’t even consider them an issue. Generally, we consider personality traits problematic (disordered) when they meet the following criteria: they are inflexible, they cause problems and distress in the person’s life or in the lives of those around that person, they create a pattern of thinking and behavior that is markedly different from the expectations for adult behavior in a person’s culture, they are enduring over time and across situations and circumstances.

  17. bmsha4
    August 23, 2017

    I have just ordered your book and am throwing myself into the information around Vulnerable Narcissism. Reading the descriptions of this personality trait / condition, is like reading a book written about my sibling. I feel so much relief now understanding where the past 30 years of belittling, countering, feelings of entitlement etc. have stemmed from. Do you have any suggestions for broaching this both with other members of the family, or with the person themselves?
    I am unable to speak to my sibling directly as they have cut me out of their life after finding out they would not be in my wedding party (a role which they consider a birthright, and responded in extreme rage). Appreciate your time and looking forward to reading your book.

    • Dr. Ettensohn
      August 31, 2017

      I hope you enjoy the book. It can feel enormously helpful to finally have a name for something, and to begin to understand the system of thoughts, feelings, and motivations that underlie problematic behavior. As far as communicating your insights with family members…you know your family best.

  18. Nic
    April 21, 2019

    Would you recommend lithium for the treatment of NPD?

    • Dr. Ettensohn
      October 11, 2019

      I am not a psychiatrist, so recommending drugs is outside the scope of my practice. Generally speaking, medication may be used to help with co-morbid issues, but NPD itself will not typically respond to medication. The only effective treatment is therapy.

  19. Curt Christiansen
    October 12, 2019

    Sir, you are so wrong! These people are evil as hell and the damage they inflict is unforgivable. My they all rule in hell.

    • Dr. Ettensohn
      December 8, 2019

      Sadly, yours is not a minority opinion. I’ve recently written a scholarly paper (in draft form) examining the intense hatred for ‘narcissists’ on the internet. Sadly, much of it comes from fundamental flaws in the DSM diagnostic criteria for NPD, which was revised in the late 1980s to remove any mentioning of the emotional distress that many (in fact, most) of those with pathological narcissism experience. Suffice it to say that pathological narcissism (like any mental illness) causes suffering for all involved parties. You may be surprised to learn that many narcissistic individuals struggle with chronic depression, debilitating anxiety, substance abuse, and suicide.


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