Narcissism: Subtypes and the Relationship With Narcissistic Personality Disorder (NPD)

Narcissism is a term which is often colloquially misunderstood, misused, and carries a negative value connotation to describe someone who is excessively self-absorbed and needing attention. Narcissism, however, is much more than that and goes beyond the traits of exhibitionism and the need for validation. Narcissism, as any personality feature, occurs on a continuum from milder forms, or even healthy narcissism, to those more maladaptive forms or pathological narcissism (Gabbard & Crisp-Han, 2016).

Amongst psychotherapists and other mental health professionals, when we refer to narcissism, we are referring to the pathological or unhealthy narcissism rather than its healthy counterpart. It is also important not to equate narcissism with narcissistic personality disorder (NPD) as defined by DSM-5 (APA, 2013) as the diagnostic criteria for the latter is much too narrow to include the versos different subtypes, manifestations, and severities of narcissism.

What is Narcissism?

Narcissism exists on a continuum from healthy to unhealthy or pathological, so a personality disorder. When referring to its unhealthy or even pathological manifestation, narcissism is a personality trait characterised by a sense of self-importance, self-absorption, the need for admiration, validation, and recognition. It is also characterised by grandiosity, arrogance, and entitlement. Narcissistic individuals tend to experience themselves as special and unique, and hence often feel misunderstood or underappreciated.

Grandiosity and constant reaffirmation of the narcissist's importance serve the purpose of defending against the underlying experience of inadequacy, impotence, powerlessness, boredom, mediocrity, internal emptiness, and meaninglessness (see also McWilliams & Shedler, 2017). It is helpful to understand the narcissist's elevated sense of self-importance, specialness, and uniqueness as forms of defence against underlying insecurities, inadequacies, and a sense of impotence.

So, the narcissist's self-esteem, which may seem high and firm, is actually built on hollow ground. This is also the reason why narcissistic individuals may either respond with rage and anger when criticised or slighted, or may become depressed, anxious, and fall into the experience of internal emptiness and boredom when faced with a failure in life.

Narcissism is also characterised by high levels of aggression, which may be conscious and overt or unconscious and hidden, along with reduced capacities for empathy and intimacy. Often, narcissistic individuals are blind to the emotional experiences of others and unaware of the impact they have on others and how others perceive them.

Narcissistic individuals have a low capacity to engage in loving relationships. They will also tend to have difficulties combining love and emotional intimacy with sex and eroticism. For them, love destroys sexual eroticism and sex destroys love.

Romantic relationships are often unstable and superficial. Even when they appear stable, such as with high-functioning narcissists, such relationships are characterised by shallowness, exploitation, control, and basking in their romantic partner's glory or beauty. Narcissists typically have an issue with their romantic partner's independence and autonomy (Gabbard & Crisp-Han, 2016), which may increase their need to control their partners practically, emotionally, or financially.

One of the distinct features of narcissism is an impairment of moral values and moral corruption. This may present itself on a continuum from mild to severe. However, when narcissism is indicated, there will normally be some impairment of moral functioning. Usually, narcissistic individuals will defend against their own moral corruption by projecting it onto others and justifying their own lack of morality as a protective mechanism against the perceived lack of morality in others.

Subtypes of Narcissism

Historically, professionals have distinguished predominantly between two subtypes of narcissism: the grandiose and the vulnerable subtype. However, research (Russ et al., 2008) has indicated another subtype, so that today we can distinguish between the following three subtypes (Diamond et al., 2022; Gabbard, 1989; Gabbard & Crisp, 2018; Rosenfeld, 1987; Russ et al., 2008):

• Grandiose, oblivious, or thick-skinned narcissism

• Vulnerable, fragile, or thin-skinned narcissism

• High-functioning or exhibitionistic narcissism

Grandiose Narcissism

Grandiose narcissism is the most prevalent type of narcissism and most closely correlates to the type of narcissism as defined by DSM-5 (APA, 2013). Grandiose narcissists tend to be self-aggrandising, entitled, exploitative, and lacking empathy (Diamond et al., 2022). They often come across as arrogant and tend to experience envy, which they may hide well from others and also project onto others, perceiving them as envious.

Grandiose narcissists have also been referred to as ‘oblivious’ (Gabbard, 1989) because they are not aware of the impact that they have on others. They may, in fact, completely discount that they are arrogant and boring and that, in relationships, they are tolerated rather than wanted.

Individuals with grandiose narcissism tend to experience themselves as special or unique and will have an exaggerated perception of self-importance. They may feel superior to others, righteous, and often tend to experience others as envying them. Because of their perceived specialness, they will tend to feel entitled. They will tend to be devaluing of others, aggressive, critical, arrogant, and will often get involved in power struggles (Russ & Shedler, 2013).

Grandiose narcissists tend to have a soft spot for power. In fact, power can be an overarching theme in their lives and may be present in all pores of their functioning—both on conscious and unconscious levels, as well as directly and indirectly. They may not only seek power and influence in their professional roles but also in their relationships, which may result in their need to control their romantic partners—either practically, emotionally, or financially. Conversely, if they consciously or unconsciously perceive themselves as lacking power or being the inferior one in the relationship, they will often tend to defend against such position fiercely as it may evoke fears of being exploited and manipulated.

Because of their underlying insecurity and lack of self-esteem that is kept unconscious, they will present with fears of rejection and abandonment by their romantic partner. As such, they may be jealous in romantic relationships and may attempt to control and limit their romantic partner’s freedom and autonomy.

Grandiose narcissists tend to be self-absorbed and draw attention to themselves. Even in conversations where they try to make it about others, they may struggle with that and be oblivious to the fact that they make it about themselves. Due to their lack of awareness of the impact they have on others or the ability to read and understand others' experiences, they tend to have poor susceptibility to social cues.

Grandiose narcissists will usually over-identify with their social, career, economic status, or the status of their family. They tend to strive for admiration and recognition from others. Because of that, they will usually take up high-profile leadership positions, such as CEOs and politicians.

Narcissists, in general, tend to have somewhat corrupt moral values. This, however, may be especially the case with the grandiose subtype of narcissism. However, they may justify these corrupt moral values as well as project them onto others. This may result in grandiose narcissists seeing their own impaired morality as a means of protecting themselves from the immorality and corruption of others.

Grandiose narcissists tend to hold grudges, be resentful, and react negatively to insults or slights, which they may have trouble getting over. They may, at times, take criticism as an insult and react disproportionately with anger or rage, whilst at other times may be completely insensitive and unsusceptible to it. When rage is evoked, it is a response to the experience of shame triggered by criticism; however, they may not be in touch with shame as it may be kept unconscious.

They will lack empathy for others to the point of having a blind spot for others’ experiences. In close relationships, they may tend to act empathically, however, this may only be the result of them trying to manipulate the other person.

Grandiose narcissists, like any type of narcissist, tend to treat others as objects whose role is to gratify their own needs. Relationships are perceived purely transactionally. Their language in social relationships revolves around manipulation, seduction, extortion, deceit, and lying. Because they project these qualities onto others, they will tend to perceive others as manipulative, exploitative, and envious of them.

Fragile or Vulnerable Narcissism

Vulnerable narcissists are also referred to as hyper vigilant or thin-skinned as they are sensitive to others’ slights and comments (Gabbard & Crisp-Han, 2016). This type of narcissism is also referred to as closet narcissism or covert narcissism.

Contrary to grandiose or thick-skinned narcissists, who pay less attention to others and more attention to themselves, vulnerable narcissists tend to be sensitive to other people's reactions to them—hence the term thin-skinned and hypervigilant. Even the slightest criticism or comment can cause deep narcissistic injury, shame, humiliation, and feelings of inferiority and inadequacy. These feelings also arise when they experience failure in their lives (Diamond et al., 2022).

Similar to grandiose narcissists, vulnerable narcissists will tend to have an exaggerated sense of self-importance, experience themselves as superior, special, entitled, and envied, and will tend to be critical of others, as well as potentially hostile (Russ & Shedler, 2013). However, due to their thin-skinned nature, their grandiosity will be more vulnerable, and they will tend to be more susceptible to feelings of emptiness, rejection, abandonment, feeling inadequate or a failure, and feeling misunderstood and underappreciated.

When feeling hurt, they may have emotional outbursts of anger, rage, resentment, and contempt. Because of their thin-skinned nature and their vulnerability to narcissistic injury and feeling hurt, vulnerable narcissists will tend to feel unhappy, depressed, and despondent (Russ & Shedler, 2013). Often, when they resent someone or feel contempt for them, it may take them a long time to get over it—at times, they may hold a grudge forever.

Vulnerable narcissists are thus more in touch with their underlying feelings of inadequacy, shame, and loneliness than grandiose narcissists. They will tend to defend agains these feelings through grandiosity, however, contrary to grandiose narcissists, such grandiosity will tend not to be well evident externally but part of their internal world. This means that they will tend to not overtly display their sense of superiority, however, careful probing into how they feel about themselves, especially in psychotherapy, will often reveal an internal world of narcissistic fantasy that is based on the perception of superiority, specialness, and uniqueness.

Contrary to grandiose narcissists, vulnerable or thin-skinned narcissists often acquire their sense of specialness through identifying and being associated with others whom they perceive to be special (Diamond et al., 2022). This means that they are likely to idealise grandiose narcissists and, when those are in positions of leadership, tend to be their followers.

Vulnerable narcissists will also tend to glorify their distress and suffering (Diamond et al., 2022) and may thus have a strong undertone of martyrdom, which they will usually display for others. They may consider themselves morally superior because of their suffering, which may result in them unconsciously involving themselves in situations where they are mistreated.

Because vulnerable narcissists, due to their thin-skinned nature, tend to be more fragile and prone to narcissistic injury—so, they may be affected by other people’s criticism and their own failure more—they will also tend to be more symptomatic, usually experiencing depression, anxiety, feelings of unworthiness and inadequacy. This, coupled with the fact that the traits of vulnerable narcissism do not fit the diagnostic criteria of narcissistic personality disorder (NPD) according to DSM-5, vulnerable narcissists tend to be misdiagnosed with depression or anxiety, whilst their underlying personality impairments tend to get missed (Diamond et al., 2022), which often results in continuous treatment failures and relapses.

High-Functioning Narcissism

The high-functioning narcissist is in some ways similar to the grandiose type; however, they are much more socially adept. It may go under the radar as people with high-functioning narcissism may be articulate, outgoing, charming, likeable, and in other ways socially pleasant and admired (Gabbard, 2022).

A high-functioning narcissist often engages in psychotherapy due to the need for admiration and a sense of importance from the fact that they are doing something about their personal development, rather than being motivated by genuine psychotherapeutic change.

Compared to other subtypes, high-functioning narcissists are more adaptable in terms of their functioning, which results in their underlying pathology being hidden from others—including clinicians. Their narcissism is what drives them to succeed (Russ & Shedler, 2013).

High-functioning narcissists are, similar to the grandiose subtype, 'thick-skinned', which means their functioning may be stable as their psychological defences prevent them from acknowledging their narcissistic injury and subsequent feelings of internal emptiness, boredom, depression, anxiety, and shame. They are thus able to maintain high self-esteem and stable but superficial and somewhat exploitative relationships, with success in their career (Diamond et al., 2022).

High-functioning narcissistic individuals will often engage in charitable and altruistic causes, especially when such causes mean that they will receive public praise for them (Diamond et al., 2022).

Contrary to other subtypes of narcissists, high-functioning narcissists may engage in long-term stable relationships, which also contributes to the illusion that they have the capacity for intimacy and love. These relationships, however, are often based on the individual's need for recognition and admiration. They may lack the capacity for love and may be based on the narcissist's need to be associated with someone who is a target of admiration. Their partners are expected to admire them. However, as soon as the partner's individuality and autonomy surface, the narcissistic individual may feel threatened. They will find comfort only in controlling their romantic partner because of their own insecurities and fears around losing them (Gabbard & Crisp-Han, 2016). They may often try to control their romantic partner practically—for instance, limiting their social contact, extracurricular activities, hobbies, interests, or work.

The Relationship Between Narcissism and Narcissistic Personality Disorder (NPD)

The DSM-5 includes two distinct diagnostic criteria for narcissistic personality disorder (NPD). The first set of criteria is the so-called categorical model of diagnosis, which has been criticised for its lack of validity and over-emphasis on observable traits. The second model is the so-called alternative model of personality disorders (AMPD), and although not optimal, it represents a step away from the categorical view of personality disorders.

NPD According to the Categorical Modal of Personality Disorders

According to the categorical model of DSM-5 (APA, 2013), narcissistic personality disorder (NPD) is defined as a personality disorder characterised by a pervasive pattern of grandiosity, the need for admiration, and lack of empathy. In terms of relationships, it is characterised by explosiveness, entitlement, arrogance, and envy.

There are nine criteria in DSM-5, of which five need to be met for clinical diagnosis of NPD. These criteria can be summed up into (APA, 2013):

• Grandiosity and self-importance;

• Fantasies of unlimited success, power, beauty, or love;

• A belief that the person is in some way ‘special’ or unique;

• The need for admiration;

• A sense of entitlement;

• Exploitative in relationships;

• Lacking empathy for others;

• Being envious of others or feeling that others are envious of them;

• Arrogance

NPD According to the Alternative Model of Personality Disorders

When considering the DSM-5 alternative model of personality disorders (AMPD) (APA, 2013), narcissistic personality disorder (NPD) is defined as a combination of deficits in personality functioning, which need to be combined with traits of grandiosity and attention seeking.

In terms of personality functioning, NPD stipulates difficulties in the following areas:

• The person's identity depends excessively on referencing others for self-definition and self-esteem, meaning their identity is defined through the eyes of other people.

• Self-direction or life goals are set based on the approval of others rather than as a reflection of the person's genuine interests.

• Empathy is impaired to the point that the person struggles to recognise or identify with the feelings or needs of others.

• Intimacy is impaired, so relationships are superficial and serve the individual's needs for self-esteem regulation.

Issues With the Diagnosis of Narcissistic Personality Disorder With DSM-5

As with any personality disorder, there are also controversies associated with diagnosing narcissistic personality disorder (NPD). This is especially the case when NPD is diagnosed according to DSM-5.

Firstly, DSM-5 is said to focus on behavioural and observable traits, not taking into account the underlying psychodynamic features. The latter has, partially, been addressed by the inclusion of the alternative model of personality disorders (AMPD) in DSM-5.

And secondly, as can be seen from the above criteria, NPD as defined by DSM-5 is a very narrow disorder and mainly corresponds to the grandiose subtype of narcissism, whilst the vulnerable and high-functioning subtypes may be missed when using the DSM-5 diagnostic criteria.

This means that, for instance, in the case of vulnerable narcissism, because the criteria for the diagnosis of narcissistic personality disorder (NPD) according to DSM-5 is so narrow, vulnerable narcissists are often misdiagnosed with borderline personality disorder (BPD) or avoidant personality disorder (Dickinson & Pincus, 2003).

Psychotherapy as Treatment of Narcissistic Personality Disorder (NPD)

People with narcissistic personality disorder (NPD), especially the grandiose and high-functioning subtypes, often do not seek treatment, particularly psychotherapy, as they may go through life experiencing limited distress. If they do experience distress, they usually do not attribute it to narcissism. In fact, they may perceive their narcissism as beneficial.

Typically, individuals with NPD enter treatment because they were forced by loved ones, often romantic partners, or because their narcissistic defences failed, leading to depression, anxiety, a sense of internal emptiness, meaninglessness, or relationship failures.

Narcissistic personality disorder (NPD), and even subclinical narcissism, is usually treated with psychotherapy. Most psychotherapeutic treatment focuses on the presenting issue or symptom the individual is experiencing—for instance, depression, anxiety, substance abuse, or relationship issues.

Some treatments, especially those informed by psychoanalytic or psychodynamic approaches, such as transference-focused psychotherapy (TFP) (Diamond et al., 2022), have been specifically modified for the treatment of narcissistic personality disorder (NPD). Such treatments target the underlying personality pathology rather than the symptoms or and may offer the prospect of resolving the internal conflicts underpinning NPD symptoms and relationship issues.

Ales Zivkovic, MSc (TA Psych), CTA(P), PTSTA(P), Psychotherapist, Counsellor, Supervisor

Ales Zivkovic is a psychotherapist, counsellor, and clinical supervisor. He holds an MSc in Transactional Analysis Psychotherapy awarded by Middlesex University in London. He is also a Provisional Teaching and Supervising Transactional Analyst (PTSTA-P) and a Certified Transactional Analyst in the field of Psychotherapy (CTA-P). Ales gained extensive experience during his work with individuals and groups in the UK National Health Service (NHS) and his private psychotherapy, counselling, and clinical supervision practice in central London, UK. He was also a member of the United Kingdom Council for Psychotherapy (UKCP). Ales works with individuals, couples, and groups. In clinical setting, he especially focuses on the treatment of issues of childhood trauma, personality disorders, and relationship issues. A large proportion of his practice involves online psychotherapy as he works with clients from all over the world. Ales developed a distinct psychotherapeutic approach called interpretive dynamic transactional analysis psychotherapy (IDTAP). More about Ales, as well as how to reach him, can be found here.

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