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Monday, September 29, 2025

Jury nullification

From Wikipedia, the free encyclopedia
The Trial of the Seven Bishops by John Rogers Herbert

Jury nullification, also known as jury equity or as a perverse verdict, is a decision by the jury in a criminal trial resulting in a verdict of not guilty even though they think a defendant has broken the law. The jury's reasons may include the belief that the law itself is unjust, that the prosecutor has misapplied the law in the defendant's case, that the punishment for breaking the law is too harsh, or general frustrations with the criminal justice system. It has been commonly used to oppose what jurors perceive as unjust laws, such as those that once penalized runaway slaves under the Fugitive Slave Act, prohibited alcohol during Prohibition, or criminalized draft evasion during the Vietnam War. Some juries have also refused to convict due to their own prejudices in favor of the defendant. Such verdicts are possible because a jury has an absolute right to return any verdict it chooses.

Nullification is not an official part of criminal procedure, but is the logical consequence of two rules governing the systems in which it exists:

  1. Jurors cannot be punished for passing an incorrect verdict.
  2. In many jurisdictions, a defendant who is acquitted cannot be tried a second time for the same offense.

A jury verdict that is contrary to the letter of the law pertains only to the particular case before it; however, if a pattern of acquittals develops in response to repeated attempts to prosecute a particular offence, this can have the de facto effect of invalidating the law. Such a pattern may indicate public opposition to an unwanted legislative enactment. It may also happen that a jury convicts a defendant even if no law was broken, although such a conviction may be overturned on appeal. Nullification can also occur in civil trials; unlike in criminal trials, if the jury renders a not liable verdict that is clearly at odds with the evidence, the judge can issue a judgment notwithstanding the verdict or order a new trial.

Background

A 19th-century jury

In the past, it was feared that a single judge or panel of government officials might be unduly influenced to follow established legal practice, even when that practice had drifted from its origins. In most modern Western legal systems, judges often instruct juries to act only as "finders of fact", whose role it is to determine the veracity of the evidence presented, the weight accorded to the evidence, to apply that evidence to the law as explained by the judge, and to reach a verdict; but not to question the law itself. Similarly, juries are routinely cautioned by courts and some attorneys not to allow sympathy for a party or other affected persons to compromise the fair and dispassionate evaluation of evidence. These instructions are criticized by advocates of jury nullification. Some commonly cited historical examples of jury nullification involve jurors refusing to convict persons accused of violating the Fugitive Slave Act by assisting runaway slaves or being fugitive slaves themselves, and refusal of American colonial juries to convict a defendant under English law.

Jury nullification is the source of much debate. Some maintain that it is an important safeguard of last resort against wrongful imprisonment and government tyranny. Some view it as a violation of the right to a jury trial, which undermines the law; whereas others, such as those members of Congress who voted to impeach Supreme Court Justice Samuel Chase for instructing a jury against nullification, view a jury as a body charged with judging both law and fact. Some view it as a violation of the oath sworn by jurors. In the United States, some view the requirement that jurors take an oath to be unlawful in itself, while still others view the oath's reference to "deliverance" to require nullification of unjust law: "will well and truly try and a true deliverance make between the United States and the defendant at the bar, and a true verdict render according to the evidence, so help [me] God". United States v. Green, 556 F.2d 71 (D.C. Cir. 1977).

Some fear that nullification could be used to permit violence against socially unpopular factions. They point to the danger that a jury may choose to convict a defendant who has not broken the letter of the law. However, judges retain the rights both to decide sentences and to disregard juries' guilty verdicts (not guilty verdicts cannot be disregarded), acting as a check against malicious juries. Jury nullification may also occur in civil suits, in which the verdict is generally a finding of liability or lack of liability (rather than a finding of guilty or not guilty).

The main ethical issue involved in jury nullification is the tension between democratic self-government and integrity. The argument has been raised that prosecutors are not allowed to seek jury nullification, and therefore defendants should not be allowed to seek it either; however, for a prosecutor to nullify a law in this context would require negating the presumption of innocence. For this reason, prosecutorial nullification is typically defined as declining to prosecute. Nevertheless, there is little doubt as to the ability of a jury to nullify the law. Today, there are several issues raised by jury nullification, such as:

  1. Whether juries can or should be instructed or informed of their power to nullify.
  2. Whether a judge may remove jurors "for cause" when they refuse to apply the law as instructed.
  3. Whether a judge may punish a juror for practicing jury nullification.
  4. Whether all legal arguments, except perhaps on motions in limine to exclude evidence, should be made in the presence of the jury.

In some cases in the United States, a stealth juror will attempt to get on a jury in order to nullify the law. Some lawyers use a shadow defense to expose the jury to information that would otherwise be inadmissible, hoping that evidence will trigger a nullification.[26][27]

Common law precedent

Even prior to Bushel's Case, Sir Nicholas Throckmorton, a non-Episcopalian English Dissenter, or Nonconformist, outside the established Church of England, was acquitted by a jury despite hostility of the judges.

The early history of juries supports the recognition of the de facto power of nullification. By the 12th century, common law courts in England began using juries for more than administrative duties. Juries were composed primarily of "laymen" from the local community and provided a somewhat efficient means of dispute resolution with the benefit of supplying legitimacy. The general power of juries to decide on verdicts was recognised in the English Magna Carta of 1215, which put into words existing practices:

No free man shall be captured, and or imprisoned, or disseised of his freehold, and or of his liberties, or of his free customs, or be outlawed, or exiled, or in any way destroyed, nor will we proceed against him by force or proceed against him by arms, but by the lawful judgment of his peers, or by the law of the land.

For a trivial offence, a free man shall be fined only in proportion to the degree of his offence, and for a serious offence correspondingly, but not so heavily as to deprive him of his livelihood. In the same way, a merchant shall be spared his merchandise, and a husbandman the implements of his husbandry, if they fall upon the mercy of a royal court. None of these fines shall be imposed except by the assessment on oath of reputable men of the neighbourhood.

Largely, the earliest juries returned verdicts in accordance with the wishes of the judge or the Crown. This was achieved either by "packing the jury" or by "writs of attaint". Juries were packed by hand-selecting or by bribing the jury so as to return the desired verdict. That was a common tactic in cases involving treason or sedition. In addition, the writ of attaint allowed a judge to retry the case in front of a second jury when the judge believed the first jury returned a "false verdict". If the second jury returned a different verdict, that verdict was imposed, and the first jury was imprisoned or fined.

That history is marked by a number of notable exceptions, several of which claim rights commonly recognized as fundamental in modern democratic societies, such as freedom of speech and of the press, and freedom of religious practice. In 1554, a jury acquitted Sir Nicholas Throckmorton but was severely punished by the court. Almost a century later, in 1649, in the first known attempt to argue for jury nullification, a jury likewise acquitted John Lilburne for his part in inciting a rebellion against Oliver Cromwell's regime. Lilburne had been charged with seditious libel for the publication of articles critical of the government; the jury were instructed to give a verdict only on whether the text was published, and to leave the issue of libel to the judge, while Lilburne argued the jury should give a general verdict and should judge whether the law's restraint on speech against the government was just. The theoretician and politician Eduard Bernstein wrote of Lilburne's trial:

His contention that the constitution of the Court was contrary to the fundamental laws of the country was unheeded, and his claim that the jury was legally entitled to judge not only as to matters of fact but also as to the application of the law itself, as the Judges represented only 'Norman intruders', whom the jury might here ignore in reaching a verdict, was described by an enraged judge as 'damnable, blasphemous heresy'. This view was not shared by the jury, which, after three days' hearing, acquitted Lilburne—who had defended himself as skillfully as any lawyer could have done—to the great horror of the Judges and the chagrin of the majority of the Council of State. The Judges were so astonished at the verdict of the jury that they had to repeat their question before they would believe their ears, but the public which crowded the judgment hall, on the announcement of the verdict, broke out into cheers so loud and long as, according to the unanimous testimony of contemporary reporters, had never before been heard in the Guildhall. The cheering and waving of caps continued for over half an hour, while the Judges sat, turning white and red in turns, and spread thence to the masses in London and the suburbs. At night bonfires were lighted, and even during the following days the event was the occasion of joyful demonstrations.

In 1653, Lilburne was on trial again and asked the jury to acquit him if it found the death penalty "unconscionably severe" in proportion to the crime he had committed. The jury found Lilburne "not guilty of any crime worthy of death". In 1670, a petit jury refused to convict William Penn of unlawful assembly for religious practice not associated with the Church of England. The judge held the jury in contempt of court, which was ruled inappropriate by the Court of Common Pleas in Bushel's Case. In 1681, a grand jury refused to indict the Earl of Shaftesbury. In 1688, a jury acquitted the Seven Bishops of the Church of England of seditious libel. Juries continued, even in non-criminal cases, to act in defiance of the Crown. In 1763 and 1765, juries awarded £4,000 to John Wilkes and £300 to John Entick in separate suits for trespass against the Crown's messengers. In both cases, messengers had been sent by Lord Halifax to seize allegedly-libellous papers.

In Scotland, jury nullification had the profound effect of introducing the three-verdict system including the option of "not proven", which remains in Scotland to this day. In 1728, Carnegie of Finhaven accidentally killed the Earl of Strathmore. As the defendant had undoubtedly killed the Earl, the law, as it then stood, required the jury merely to look at the facts and to pass a verdict of "proven" or "not proven", depending on whether it believed that the facts proved the defendant had killed the Earl. If the jury brought in a "proven" verdict, that would lead to Carnegie's hanging though he had not intended any harm to the Earl. To avert that injustice, the jury decided to assert what it believed to be its "ancient right" to judge the whole case, not just the facts, and rendered the verdict of "not proven". Over time, juries have tended to favour the "not guilty" verdict over "not proven" and so the interpretation has changed. The "not guilty" verdict has become the normal verdict when a jury is convinced of innocence, and the "not proven" verdict is used only if the jury is not certain of innocence or guilt.

The standard jury trial practice in the United States during the Founding Era and for several decades afterward was to argue all issues of law in the presence of the jury so that it heard the same arguments as the bench in reaching its rulings on motions. That is evidenced by such decisions as the 1839 case Stettinius, which held, "The defense can argue law to the jury before the court gives instructions." Later, judges began to demand the parties submit motions in writing, often before the jury was empaneled, to be argued and decided without the jury being present. The transition began with motions in limine to exclude evidence on which it was felt the jury should not hear the argument because it would be informed of the evidence to be excluded. Later, that was expanded to include all legal argument and so that today, the earlier practice of arguing law before the jury has been largely forgotten, and judges even declare mistrials or overturn verdicts if legal arguments are made to the jury.

Specific jurisdictions

Canada

Although extremely rare, jury nullification occurs in Canada. As the prosecution has powers to appeal the resulting acquittal, it lacks the finality found in the United States. However, the Crown cannot appeal on grounds of an unreasonable acquittal although it can appeal on errors of law. In R. v. Latimer, 2001 SCC 1, the Supreme Court discussed jury nullification and indicated that it is a duty of the presiding justice to try to prevent it from occurring. Perhaps the most famous cases of jury nullification in Canada were the various trials of Henry Morgentaler, who openly operated a private abortion clinic in violation of the Criminal Code. Repeated attempts at prosecuting Morgentaler resulted in acquittals at jury trials in the 1970s and the 1980s. In the 1988 Supreme Court case, R. v. Morgentaler, 1988 SCR 30, a nullification was appealed all the way to the country's highest court, which struck down the law in question. In obiter dicta, Chief Justice Dickson wrote:

The contrary principle contended for by Mr. Manning, that a jury may be encouraged to ignore a law it does not like, could lead to gross inequities. One accused could be convicted by a jury who supported the existing law, while another person indicted for the same offence could be acquitted by a jury who, with reformist zeal, wished to express disapproval of the same law. Moreover, a jury could decide that although the law pointed to a conviction, the jury would simply refuse to apply the law to an accused for whom it had sympathy. Alternatively, a jury who feels antipathy towards an accused might convict despite a law which points to acquittal. To give a harsh, but I think telling example, a jury fueled by the passions of racism could be told that they need not apply the law against murder to a white man who had killed a black man. Such a possibility need only be stated to reveal the potentially frightening implications of Mr. Manning's assertions.... It is no doubt true that juries have a de facto power to disregard the law as stated to the jury by the judge. We cannot enter the jury room. The jury is never called upon to explain the reasons which lie behind a verdict. It may even be true that in some limited circumstances the private decision of a jury to refuse to apply the law will constitute, in the words of a Law Reform Commission of Canada working paper, "the citizen's ultimate protection against oppressive laws and the oppressive enforcement of the law" (Law Reform Commission of Canada, Working Paper 27, The Jury in Criminal Trials (1980)). But recognizing this reality is a far cry from suggesting that counsel may encourage a jury to ignore a law they do not support or to tell a jury that it has a right to do so.

The Supreme Court in 2006 issued a decision, R. v. Krieger, 2006 SCC 47, which confirmed that juries in Canada have the power to refuse to apply the law when their consciences require that they do so. The decision stated that "juries are not entitled as a matter of right to refuse to apply the law—but they do have the power to do so when their consciences permit of no other course".

England and Wales

By the late 17th century, the court's power to punish juries was removed in Bushel's Case involving a juror on the case against William Penn. Penn and William Mead had been arrested in 1670 for illegally preaching a Quaker sermon and disturbing the peace but four jurors, led by Edward Bushell, refused to find them guilty. Instead of dismissing the jury, the judge sent them back for further deliberations. Despite the judge demanding a guilty verdict, the jury now unanimously found Penn guilty of preaching but acquitted him on the charge of disturbing the peace and acquitted Mead of all charges. The jury was then subsequently kept for three days without "meat, drink, fire and tobacco" to force it to bring in a guilty verdict. When it failed to do so, the judge ended the trial. As punishment, the judge ordered the jurors imprisoned until they paid a fine to the court.

Plaque at the Old Bailey

Four jurors refused to pay the fine, and after several months, Bushell sought a writ of habeas corpus. Chief Justice Vaughan, sitting on the Court of Common Pleas, discharged the writ, released them, called the power to punish a jury "absurd" and forbade judges from punishing jurors for returning a verdict the judge disagreed with. That series of events is considered a significant milestone in the history of jury nullification. The "courage and endurance" of the jury is celebrated in a plaque displayed in the Central Criminal Court (the Old Bailey) in London. In a criminal libel case, R. v. Shipley (1784), 4 Dougl. 73, 99 E.R. 774, at p. 824, Lord Mansfield, sitting as a judge in the case, disparaged the practice of jury nullification:

So the jury who usurp the judicature of law, though they happen to be right, are themselves wrong, because they are right by chance only, and have not taken the constitutional way of deciding the question. It is the duty of the Judge, in all cases of general justice, to tell the jury how to do right, though they have it in their power to do wrong, which is a matter entirely between God and their own consciences.

To be free is to live under a government by law.... Miserable is the condition of individuals, dangerous is the condition of the State, if there is no certain law, or, which is the same thing, no certain administration of law, to protect individuals, or to guard the State.

...

In opposition to this, what is contended for? – That the law shall be, in every particular cause, what any twelve men, who shall happen to be the jury, shall be inclined to think; liable to no review, and subject to no control, under all the prejudices of the popular cry of the day, and under all the bias of interest in this town, where thousands, more or less, are concerned in the publication of newspapers, paragraphs, and pamphlets. Under such an administration of law, no man could tell, no counsel could advise, whether a paper was or was not punishable [for publishing a libel].

A 2016 study exploring the history of juror punishment in England and Wales after Bushel's Case found no clear examples of jurors being punished solely for returning the "wrong" verdict. The closest that a jury came to that was in 1917, when a jury acquitted two teenage boys of arson. The boys had confessed at their pre-trial hearing but entered pleas of not guilty at their trial. Home Office civil servants suspected the difference between the pleas could be explained by the difference between the boys' admitting that they had caused the fire and their denial that they had done so maliciously. The trial judge did not consider that possibility or was not satisfied with it. On receiving the jury's verdict, he told them that "you have been absolutely regardless of your oath. These men have pleaded guilty, and the evidence is of the clearest possible nature. You are none of you fit to serve on a Jury, but you will remain here until the end of the Sessions". The foreman, George Lathan, considered that a form of punishment for the jury, as the jurors were not going to be permitted to serve on any more juries but were nonetheless required to keep attending court or face contempt proceedings, which Lathan considered a tacit form of imprisonment. Officials in the Lord Chancellor's Office noted that while the judge's conduct "was ill-judged and arbitrary, he did not, so far as I can see, do any act which would justify the Lord Chancellor in removing him from the Bench". Home Office officials wrote to the judge, advising him that his actions "would be impossible for the Home Secretary to defend as constitutional or right", and after several days, the jurors were relieved of their duties. Home Office minutes suggest they did not think that kind of informal punishment of jurors who had returned the "wrong" verdict to be unheard of.

In 1982, during the Falklands War, the Royal Navy sank the Argentine cruiser, General Belgrano. Three years later a civil servant, Clive Ponting, leaked two government documents concerning the sinking of the cruiser to a Member of Parliament (Tam Dalyell) and was subsequently charged with breaching section 2 of the Official Secrets Act 1911. The prosecution in the case demanded that the jury convict Ponting, as he had clearly contravened the Act by leaking official information about the sinking of the Belgrano during the Falklands War. His main defence was that it was in the public interest that the information be made available. The judge, Sir Anthony McCowan, "indicated that the jury should convict him", and had ruled that "the public interest is what the government of the day says it is". The jury acquitted him instead, much to the consternation of the government. In 2001, two people were charged with conspiracy to cause criminal damage to a Trident submarine in a Barrow-in-Furness shipyard. Though the two admitted their intention to trash the submarine, the two said they were planning to do so due to nuclear bombs being immoral and illegal. The judge told the juries that such ideals were not a defence against the charge. The jury brought a verdict of not guilty on these two anti-nuclear protesters.

In 2021, six activists associated with the environmental protest organisation Extinction Rebellion were tried for causing criminal damage to the British headquarters of the multinational oil company Royal Dutch Shell. The judge told the jury that there was 'no defence in law' for the protestors' actions, which according to the prosecutor had caused 'significant damage' to the building, but the activists were acquitted. In 2023, Insulate Britain members Giovanna Lewis and Amy Pritchard were jailed for seven weeks after defying the judge's ban on informing the jury of the reasons for their actions. In charging them with contempt, the judge referred to an earlier case where another environmental activist was sentenced to eight weeks in prison for the same reason. Following juries acquitting activists, dozens of people have been threatened with arrest for displaying signs that remind jurors of their right to make decisions based on conscience. In 2024, a motion brought by government lawyers to prosecute the activist Trudi Warner for holding a placard stating the right to jury nullification was thrown out by a High Court judge on the basis that there was a well-established principle in law of jury equity and Warner had not broken any law. Warner's placard had directly referenced the wording on the plaque inside the Old Bailey.

Germany

In 1921, an Armenian genocide survivor, Soghomon Tehlirian, assassinated Talaat Pasha, who was considered the main architect of the genocide, in Berlin. Although Tehlirian's lawyers did not contest that their client had killed Talaat, the jury (Germany used jury trials until 1924) returned a verdict of not guilty. However, although the moral dimension of the case was strongly emphasised by the defense, the acquittal was based on a plead of temporary insanity and there was no dissent between court and jury.

United States

In the United States, jury nullification first appeared just before the American Revolutionary War, when colonial juries frequently exercised their nullification power, principally in maritime cases and cases implicating free speech. Jury nullification became so common that many British prosecutors gave up trying maritime cases since conviction seemed hopeless. Before the American Civil War, juries sometimes refused to convict for violations of the Fugitive Slave Act. Later, during Prohibition, juries often nullified alcohol control laws. That resistance may have contributed to the adoption of the Twenty-first Amendment, which repealed Prohibition and the Eighteenth Amendment.

In a well-known example of jury nullification, at the end of Wild Bill Hickok's trial for the manslaughter of Davis Tutt in 1865, Judge Sempronius Boyd gave the jury two instructions. He first instructed the jury that a conviction was its only option under the law. He then instructed them that they could apply the unwritten law of the "fair fight" and acquit. Hickok was acquitted; the verdict was not necessarily universally popular with the press and public. There have been contemporary instances of activists being arrested for informing jurists of their right of jury nullification in front of court houses, with subsequent rulings that arresting people for this activity is unconstitutional.

Fugitive Slave Act

Juries across the North acquitted defendants who had clearly breached the Fugitive Slave Act in the 1850s. Part of the Compromise of 1850, it had been passed to mollify Southern slaveowners, who were otherwise threatening to secede from the Union. Secretary of State Daniel Webster was a key supporter of the law as expressed in his famous "Seventh of March" speech. He wanted high-profile convictions, but the jury nullifications ruined his presidential aspirations and his last-ditch efforts to find a compromise between North and South. Webster led the prosecution when defendants were accused of rescuing Shadrach Minkins in 1851 from Boston officials who intended to return Minkins to his owner. The juries convicted none of the men. Webster tried to enforce a law that was extremely unpopular in the North, and his Whig Party passed over him again when it chose a presidential nominee in 1852.

After Civil War

White defendants accused of crimes against black people and other minorities were often acquitted by all-white juries, especially in the South, even in the face of irrefutable evidence. An example is the trial of Roy Bryant and J. W. Milam.

21st century

In the 21st century, many discussions of jury nullification center on drug laws, which some consider unjust in principle or because they are seen to discriminate against certain groups. A jury nullification advocacy group estimated in 2016 that 3–4% of all jury trials involve nullification.

Judicial opinion

In the 1895 case of Sparf v. United States, written by Associate Justice John Marshall Harlan, the US Supreme Court held 5-4 that a trial judge has no responsibility to inform the jury of the right to nullify laws. That decision, often cited, has led to a common practice by US judges to penalize anyone who attempts to present a nullification argument to jurors and to declare a mistrial if such argument has been presented to them. In some states, jurors are likely to be struck from the panel during voir dire if they do not agree to accept as correct the rulings and instructions of the law as provided by the judge.

In later rulings, the courts continued to prohibit informing juries about jury nullification. In a 1969, Fourth Circuit Court of Appeals decision, U.S. v. Moylan, 417 F.2d 1002 (4th Cir.1969), the Court affirmed the concept of jury nullification, but upheld the power of a court to refuse to permit an instruction to the jury to this effect. In 1972, in United States v. Dougherty, 473 F.2d 1113, the United States Court of Appeals for the District of Columbia Circuit issued a ruling similar to Moylan that affirmed the de facto power of a jury to nullify the law but upheld the denial of the defense's chance to instruct the jury about the power to nullify.

In 1988, the Sixth Circuit upheld a jury instruction: "There is no such thing as valid jury nullification." In United States v. Thomas (1997), the Second Circuit ruled that jurors can be removed if there is evidence that they intend to nullify the law. The Supreme Court has not recently confronted the issue of jury nullification. In 2017, a jury was instructed: "You cannot substitute your sense of justice, whatever that means, for your duty to follow the law, whether you agree with it or not. It is not for you to determine whether the law is just or whether the law is unjust. That cannot be your task. There is no such thing as valid jury nullification. You would violate your oath and the law if you willfully brought a verdict contrary to the law given to you in this case." The Ninth Circuit upheld the first three sentences of the jury's instruction and overruled the remainder but deemed that instruction a harmless error and affirmed the conviction.

State laws

In 2002, South Dakota voters rejected by a 78% margin a state constitutional amendment to permit criminal defendants to argue for jury nullification. On June 18, 2012, the New Hampshire General Court enacted a law explicitly allowing defense attorneys to inform juries about jury nullification. On October 24, 2014, the New Hampshire Supreme Court effectively nullified the law and held that the wording of the statute does not allow defense attorneys to tell juries they can nullify a law. The Maryland State Constitution, Declaration of Rights, states that "in the trial of all criminal cases, the Jury shall be the Judges of Law, as well as of fact, except that the Court may pass upon the sufficiency of the evidence to sustain a conviction." Nevertheless, the Maryland Courts jury service brochure states that "it is your duty to accept what the judge is saying about the law, and how it is to be applied to the case."

Narcissistic personality disorder

From Wikipedia, the free encyclopedia
Narcissistic personality disorder
Painting of Narcissus by Caravaggioq
Narcissus (1597–99) by Caravaggio; the man in love with his own reflection

SpecialtyPsychiatry, clinical psychology
SymptomsExaggerated feelings of self-importance, excessive craving for admiration, reduced levels of empathy
Usual onsetEarly adulthood
DurationLong term
CausesA combination of genetic and environmental factors. Social theories of NPD are weak and causality is unclear.
Diagnostic methodBased on symptoms
Differential diagnosisBipolar disorder, mania and hypomania, antisocial personality disorder, substance abuse, borderline personality disorder, histrionic personality disordergrandiose delusions.
TreatmentPsychotherapy, pharmaceuticals for comorbid disorders
Prevalence0.5% to 6.2%

Narcissistic personality disorder (NPD) is a personality disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a diminished ability to empathize with other people's feelings. It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability.

Personality disorders are a class of mental disorders characterized by enduring and inflexible maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by any culture. These patterns develop by early adulthood, and are associated with significant distress or impairment. Criteria for diagnosing narcissistic personality disorder are listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), while the International Classification of Diseases (ICD) contains criteria only for a general personality disorder since the introduction of the latest edition.

There is no standard treatment for NPD. Its high comorbidity with other mental disorders influences treatment choice and outcomes. Psychotherapeutic treatments generally fall into two categories: psychoanalytic/psychodynamic and cognitive behavioral therapy, with growing support for integration of both in therapy. However, there is an almost complete lack of studies determining the effectiveness of treatments. One's subjective experience of the mental disorder, as well as their agreement to and level of engagement with treatment, are highly dependent on their motivation to change.

Signs and symptoms

Individuals with narcissistic personality disorder may be grandiose or self-loathing, extraverted or socially isolated, captains of industry or unable to maintain steady employment, model citizens or prone to antisocial activities.

NPD is complex and far from uniform in its presentation and consequences. Empirical evidence suggests several subtypes of NPD may exist (see the Subtypes section below), but in general the disorder is known to have grandiose ("thick-skinned") and vulnerable ("thin-skinned") expressions.

Grandiose, thick-skinned NPD patients show a sense of uniqueness or superiority, attitudes of entitlement, a belief that others envy their abilities or status, low empathy, social dominance, superficial charm, disdainfulness or snobbery, and an exploitative interpersonal style characterised by manipulation and selfishness.

Vulnerable, thin-skinned individuals with NPD also show entitlement, selfishness and low empathy, but uniquely demonstrate feelings of shame and inferiority, are envious of others' abilities or status, tend to be shy, paranoid, vindictive, and emotionally dependent on admiration, and show extreme rage and hostility in response to rejection and criticism.

While vulnerable-type patients typically show extreme distress and dysfunction, grandiose variants tend to be associated with greater psychological wellbeing, often manifesting dysfunction by occupational conflict, harming others, antisocial behaviour or emotional strain resulting from perfectionism.

It is often theorised that some patients may oscillate between grandiosity and vulnerability. While some evidence suggests that grandiose individuals show occasional reactive anger (a vulnerable trait), but narcissistically vulnerable individuals do not show signs of grandiosity, most studies show the vulnerable individuals show occasional bouts of grandiosity, but narcissistically grandiose individuals show few or no signs of vulnerability.

Other features

NPD patients may have difficulty accepting help. They may also exhibit vengeful fantasies, as well as violent and antisocial behaviour. They are more likely to try forms of plastic surgery due to a desire to gain attention and to be seen as beautiful.

Patients with NPD have an impaired ability to recognize facial expressions or mimic emotions, as well as a lower capacity for emotional empathy and emotional intelligence but preserved capacity for cognitive empathy or an impaired theory of mind. People with NPD are less likely to engage in prosocial behavior. They can still act in selfless ways to improve others' perceptions of them, advance their social status, or if explicitly told to. Despite these characteristics, they are more likely to overestimate their capacity for empathy. Recent work, however, suggests narcissistic empathy deficits may be resolved (at least in part) by instructed perspective-taking.

It is common for people with NPD to have difficult relationships. They may disrespect others' boundaries or idealize and devalue them. They commonly keep people emotionally distant, and project, deny, or split. NPD individuals manifesting vulnerability tend to become enraged when rejected or criticised, and may degrade, insult, or blame others who disagree with them.

NPD may be associated with reduced insight into symptoms, especially in severe cases. However, work on lower levels of narcissism suggests such individuals are not only aware of their traits but see them in a positive light, and strive to maintain them over time. Given the high-function sociability associated with narcissism, some people with NPD might not view such a diagnosis as a functional impairment to their lives.

Although overconfidence tends to make people with NPD very ambitious, such a mindset does not necessarily lead to professional high achievement and success, because they refuse to take risks, in order to avoid failure or the appearance of failure. Moreover, the psychological inability to tolerate disagreement, contradiction, and criticism makes it difficult for persons with NPD to work cooperatively or to maintain long-term relationships.

Diagnosis

A diagnosis of NPD, like other personality disorders, is made by a qualified healthcare professional in a clinical interview. Diagnostic frameworks for personality disorders differ in whether their approach categorical or dimensional; with the former (e.g., DSM-5 and ICD-10) classifying personality disorders as distinct categories, while others (e.g., ICD-11 and AMPD) classify them based on severity and elevated pathological trait domains. The AMPD contains a specific predefined trait and impairment profile of NPD, while the ICD-11 only defines a general system for rating personality disorder and trait specifiers. Differential diagnosis is used in order to determine whether NPD is the most appropriate diagnosis.

DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) retains the categorical approach to personality disorders from previous editions, with criteria remaining the same as they were in the previous DSM-IV-TR. The personality disorders are grouped into three clusters, with NPD belonging to cluster B, the disorders belonging to which often appear dramatic, emotional, or erratic. NPD is defined by a subject meeting at least five of nine specified criteria, with the DSM-5 indicating that: "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." The DSM-5 indicates that, in order to qualify as symptomatic of NPD, the person's manifested personality traits must substantially differ from social norms.

Alternative model

Section III of both the DSM-5 and DSM-5-TR contains the Alternative DSM-5 Model for Personality Disorders (AMPD). The AMPD defines six specific personality disorders – one of them being NPD – in terms of a description of the disorder; the characteristic manner in which the disorder impacts personality functioning, i.e. identity, self-direction, empathy and intimacy (criterion A); as well as a listing and description of the pathological personality traits associated with the disorder (criterion B).

General personality impairment in individuals with NPD, as described in the AMPD, involves a fragile or exaggerated self-image that depends on others' approval, leading to unstable self-esteem. Their personal goals are often shaped by a need for recognition, with standards that are either unrealistically high or based on entitlement. They struggle to recognize others’ feelings unless directly relevant to themselves and often misjudge their own impact on others. Relationships are typically superficial, serving self-enhancement rather than mutual connection. At least two of these elements must have a "moderate or greater impairment".

The AMPD lists the following pathological traits, both of which are required: grandiosity and attention-seeking; each of these is followed by a description of how the trait manifests in NPD. The AMPD specifiers allow for additional traits to be specified; it suggests additional antagonistic traits for "malignant", and traits of negative affectivity for "vulnerable" manifestations of NPD.

The patient must also meet the general criteria C through G for a personality disorder, which state that the traits and symptoms being displayed by the patient must be stable and unchanging over time with an onset of at least adolescence or early adulthood, visible in a variety of situations, not caused by another mental disorder, not caused by a substance or medical condition, and abnormal in comparison to a person's developmental stage and culture/religion.

ICD-11 and ICD-10

The World Health Organization's ICD-11 has replaced the categorical classification of personality disorders in the ICD-10 with a dimensional model containing a unified personality disorder (6D10) with severity specifiers, along with specifiers for prominent personality traits or patterns (6D11). Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder, while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.

Studies have shown that NPD corresponds well to the ICD-11 trait of Dissociality (6D11.2) – especially self-centredness (grandiosity, attention-seeking, entitlement and egocentricity; Dissociality also includes lack of empathy), which "can be manifested as an expectation of others’ admiration, attention-seeking behaviours to ensure being the center of others’ focus, and anger or denigration of others when the admiration and attention that the individual expects are not granted." Vulnerable features are associated with Negative Affectivity (6D11.0), which "may characterize some individuals with vulnerable narcissism who are ruminating over perceived slights or insults from others, are overreactive to criticism, and have a low frustration tolerance that easily makes them become overtly or covertly upset over even minor issues."

NPD also shows secondary links to Anankastia (6D11.4) and Disinhibition (6D11.3). The connection to Anankastia may reflect perfectionistic traits that support grandiosity and competitiveness, while the link to Disinhibition may involve impulsivity, overconfidence, and difficulty with long-term planning. The complex and variable trait profile across ICD-11 domains reflects the diverse presentations of narcissism. The involvement of multiple domains supports the traditional view that narcissistic pathology entails moderate to severe impairments in personality functioning.

In the previous edition, the ICD-10, narcissistic personality disorder is listed under the category of other specific personality disorders (F60.8), meaning the ICD-10 required that cases otherwise described as NPD in the DSM-5 would only need to meet a general set of diagnostic criteria.

Differential diagnosis

The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders. People with a fragile variant of NPD (see Subtypes) are prone to bouts of psychological depression, often to the degree that meets the clinical criteria for a co-occurring depressive disorder. NPD is associated with the occurrence of bipolar disorder and substance use disorders,especially cocaine use disorder. NPD may also be comorbid or differentiated with the occurrence of other mental disorders, including histrionic personality disorder, borderline personality disorder, antisocial personality disorder, or paranoid personality disorder. NPD should also be differentiated from mania and hypomania as these cases can also present with grandiosity, but present with different levels of functional impairment. It is common for children and adolescents to display personality traits that resemble NPD, but such occurrences are usually transient, and register below the clinical criteria for a formal diagnosis of NPD.

Subtypes

Although the DSM-5 diagnostic criteria for NPD has been viewed as homogeneous, there are a variety of subtypes used for classification of NPD. There is poor consensus on how many subtypes exist, but there is broad acceptance that there are at least two: grandiose or overt narcissism, and vulnerable or covert narcissism. However, none of the subtypes of NPD are recognized in the DSM-5 or in the ICD-11.

Empirically verified subtypes

Some research has indicated the existence of three subtypes of NPD, which can be distinguished by symptom criteria, comorbidity and other clinical criteria. These are as follows:

Grandiose/overt: the group exhibits grandiosity, entitlement, interpersonal exploitativeness and manipulation, pursuit of power and control, lack of empathy and remorse, and marked irritability and hostility. This group was noted for high levels of comorbid antisocial and paranoid personality disorders, substance abuse, externalizing, unemployment and greater likelihood of violence. Of note, Russ et al. observed that this group "do not appear to suffer from underlying feelings of inadequacy or to be prone to negative affect states other than anger", an observation corroborated by recent research which found this variant to show strong inverse associations with depressive, anxious-avoidant, and dependant/victimised features.

Vulnerable/covert: this variant is defined by feelings of shame, envy, resentment, and inferiority (which is occasionally "masked" by arrogance), entitlement, a belief that one is misunderstood or unappreciated, and excessive reactivity to slights or criticism. This variant is associated with elevated levels of neuroticism, psychological distress, depression, and anxiety. In fact, recent research suggests that vulnerable narcissism is mostly the product of dysfunctional levels of neuroticism. Vulnerable narcissism is sometimes comorbid with diagnoses of avoidant, borderline and dependent personality disorders.

High-functioning/exhibitionistic: A third subtype for classifying people with NPD, initially theorized by psychiatrist Glen Gabbard, is termed high functioning or exhibitionistic. This variant has been described as "high functioning narcissists [who] were grandiose, competitive, attention-seeking, and sexually provocative; they tended to show adaptive functioning and utilize their narcissistic traits to succeed." This group has been found to have relatively few psychological issues and high rates of obsessive-compulsive personality disorder, with excessive perfectionism posited as a potential cause for their impairment.

Others

Oblivious/hypervigilant: Glen Gabbard described two subtypes of NPD in 1989, later referred to as equivalent to, the grandiose and vulnerable subtypes. The first was the "oblivious" subtype of narcissist, equivalent to the grandiose subtype. This group was described as being grandiose, arrogant and thick-skinned, while also exhibiting personality traits of helplessness and emotional emptiness, low self-esteem and shame. These were observed in people with NPD to be expressed as socially avoidant behavior in situations where self-presentation is difficult or impossible, leading to withdrawal from situations where social approval is not given.

The second subtype Gabbard described was termed "hypervigilant", equivalent to the vulnerable subtype. People with this subtype of NPD were described as having easily hurt feelings, an oversensitive temperament, and persistent feelings of shame.

Communal narcissism: A fourth type is the communal narcissist. Communal narcissism is a form of narcissism that occurs in group settings. It is characterized by an inflated sense of importance and a need for admiration from others. In relation to the grandiose narcissist, a communal narcissist is arrogant and self-motivating, and shares the sense of entitlement and grandiosity. However, the communal narcissist seeks power and admiration in the communal realm. They see themselves as altruistic, saintly, caring, helpful, and warm. Individuals who display communal narcissism often seek out positions of power and influence within their groups.

Millon's subtypes

In the study Disorders of Personality: DSM-IV-TM and Beyond (1996), Theodore Millon suggested five subtypes of NPD, although he did not identify specific treatments per subtype.


Subtype Personality Traits
Unprincipled narcissist Deficient conscience; unscrupulous, amoral, disloyal, fraudulent, deceptive, arrogant, exploitive; a con artist and charlatan; dominating, contemptuous, vindictive.
Amorous narcissist Sexually seductive, enticing, beguiling, tantalizing; glib and clever; disinclined to real intimacy; indulges hedonistic desires; bewitches and inveigles others; pathological lying and swindling. Tends to have many affairs, often with exotic partners.
Compensatory narcissist Seeks to counteract or cancel out deep feelings of inferiority and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, noteworthy; self-worth results from self-enhancement.
Elitist narcissist Feels privileged and empowered by virtue of special childhood status and pseudo-achievements; entitled façade bears little relation to reality; seeks favored and good life; is upwardly mobile; cultivates special status and advantages by association.
Normal narcissist Least severe and most interpersonally concerned and empathetic, still entitled and deficient in reciprocity; bold in environments, self-confident, competitive, seeks high targets, feels unique; talent in leadership positions; expecting recognition from others.

Masterson's subtypes (exhibitionist and closet)

In 1993, James F. Masterson proposed two subtypes for pathological narcissism, exhibitionist and closet. Both fail to adequately develop an age- and phase- appropriate self because of defects in the quality of psychological nurturing provided, usually by the mother. A person with exhibitionist narcissism is similar to NPD described in the DSM-IV and differs from closet narcissism in several ways. A person with closet narcissism is more likely to be described as having a deflated, inadequate self-perception and greater awareness of emptiness within. A person with exhibitionist narcissism would be described as having an inflated, grandiose self-perception with little or no conscious awareness of feelings of emptiness. Such a person would assume that their condition was normal and that others were just like them. A person with closet narcissism is described to seek constant approval from others and appears similar to those with borderline personality disorder in the need to please others. A person with exhibitionist narcissism seeks perfect admiration all the time from others.

Malignant narcissism

Malignant narcissism, a term first coined in Erich Fromm's 1964 book The Heart of Man: Its Genius for Good and Evil, is a syndrome consisting of a combination of NPD, antisocial personality disorder, and paranoid traits. A person with malignant narcissism was described as deriving higher levels of psychological gratification from accomplishments over time, suspected to worsen the disorder. Because a person with malignant narcissism becomes more involved in psychological gratification, it was suspected to be a risk factor for developing antisocial, paranoid, and schizoid personality disorders. The term malignant is added to the term narcissist to indicate that individuals with this disorder have a severe form of narcissistic disorder that is characterized also by features of paranoia, psychopathy (anti-social behaviors), aggression, and sadism.

Historical demarcation of grandiose and vulnerable types

Over the years, many clinicians and theorists have described two variants of NPD akin to the grandiose and vulnerable expressions of trait narcissism. Some examples include:



Grandiose Phenotype Vulnerable Types
Kohut & Wolf (1978) Mirror-hungry Ideal-hungry
Broucek (1982) Egotistical Dissociative
Rosenfeld (1987) Thick-skinned Thin-skinned
Gabbard (1989, 1998, 2009) Oblivious Hypervigilant
Gersten (1991) Overly grandiose Overly vulnerable
Wink (1992) Willful Hypersensitive
Masterson (1993) Exhibitionist Closet
Fiscalini (1993) Special child Shamed child
Cooper and Maxwell (1995) Empowered Disempowered

Assessment and screening

Narcissistic Personality Inventory

Risk factors for NPD and grandiose/overt and vulnerable/covert subtypes are measured using the narcissistic personality inventory, an assessment tool originally developed in 1979, which has undergone multiple iterations with new versions in 1984, 2006 and 2014. It captures principally grandiose narcissism, but also seems to capture elements of vulnerability. A popular three-factor model has it that grandiose narcissism is assessed via the Leadership/Authority and Grandiose/Exhibitionism facets, while a combination of grandiose and vulnerable traits are indexed by the Entitlement/Exploitativeness facet.

Pathological Narcissism Inventory

The Pathological Narcissism Inventory (PNI) was designed to measure fluctuations in grandiose and vulnerable narcissistic states, similar to what is ostensibly observed by some clinicians (though empirical demonstration of this phenomenon is lacking). While having both "grandiosity" and vulnerability scales, empirically both seem to primarily capture vulnerable narcissism.

The PNI scales show significant associations with parasuicidal behavior, suicide attempts, homicidal ideation, and several aspects of psychotherapy utilization.

Five-Factor Narcissism Inventory

In 2013, the Five-Factor Narcissism Inventory (FFNI) was defined as a comprehensive assay of grandiose and vulnerable expressions of trait narcissism. The scale measures 11 traits of grandiose narcissism and 4 traits of vulnerable narcissism, both of which correlate with clinical ratings of NPD (with grandiose features of arrogance, grandiose fantasies, manipulativeness, entitlement and exploitativeness showing stronger relations). Later analysis revealed that the FFNI actually measures three factors:

  1. Agentic Extraversion: an exaggerated sense of self-importance, grandiose fantasies, striving for greatness and acclaim, social dominance and authoritativeness, and exhibitionistic, charming interpersonal conduct.
  2. Self-Centred Antagonism: disdain for others, psychological entitlement, interpersonally exploitative and manipulative behaviour, lack of empathy, anger in response to criticism or rebuke, suspiciousness, and thrill-seeking.
  3. Narcissistic Neuroticism: shame-proneness, oversensitivity and negative emotionality to criticism and rebuke, and excessive need for admiration to maintain self-esteem.

Grandiose narcissism is a combination of agency and antagonism, and vulnerability is a combination of antagonism and neuroticism. The three factors show differential associations with clinically important variables. Agentic traits are associated with high self-esteem, positive view of others and the future, autonomous and authentic living, commitment to personal growth, sense of purpose in life and life satisfaction. Neurotic traits show precisely the opposite correlation with all of these variables, while antagonistic traits show more complex associations; they are associated with negative view of others (but not necessarily of the self), a sense of alienation from their 'true self', disinterest in personal growth, negative relationships with others, and all forms of aggression.

Millon Clinical Multiaxial Inventory

The Millon Clinical Multiaxial Inventory (MCMI) is another diagnostic test developed by Theodore Millon. The MCMI includes a scale for narcissism. The NPI and MCMI have been found to be well correlated. Whereas the MCMI measures narcissistic personality disorder (NPD), the NPI measures narcissism as it occurs in the general population; the MCMI is a screening tool. In other words, the NPI measures "normal" narcissism; i.e., most people who score very high on the NPI do not have NPD. Indeed, the NPI does not capture any sort of narcissism taxon as would be expected if it measured NPD.

A 2020 study found that females scored significantly higher on vulnerable narcissism than males, but no gender differences were found for grandiose narcissism.

Causes

Aetiology

The cause of narcissistic personality disorder (NPD) is unclear, although there is evidence for a strong biological or genetic underpinning. It is unclear if or how much a person's upbringing contributes to the development of NPD, although many speculative theories have been proposed.

Evidence to support social factors in the development of NPD is limited. Some studies have found NPD correlates with permissive and overindulgent parenting in childhood, while others have found correlations with harsh discipline, neglect or abuse. Findings have been inconsistent, and scientists do not know if these correlations are causal, as these studies do not control for genetic confounding.

This problem of genetic confounding is explained by psychologist Svenn Torgersen in a 2009 review:

If parents treat their children badly, and the children develop personality disorders, it does not necessarily mean that the treatment of the children is the cause of the development. An alternative explanation may be that the parents themselves have some personality disorder traits, partly due to genes. These genetically influenced traits correlate with poor parenting, explaining the genetic influence on parenting. The children inherit the genes and subsequently develop personality disorders. The personality disorders might thus have developed in any case, independent of the childhood conditions.

Twin studies allow scientists to assess the influence of genes and environment, in particular, how much of the variation in a trait is attributed to the "shared environment" (influences shared by twins, such as parents and upbringing) or the "unshared environment" (measurement error, noise, differing illnesses between twins, randomness in brain growth, and social or non-social experiences that only one twin experienced). According to a 2018 review, twin studies of NPD have found little or no influence from the shared environment, and a major contribution of genes and the non-shared environment:

Taken together, these studies have consistently demonstrated that genetic influence constitutes a major source of NPD. Non-shared environments also exert substantial influence on NPD. Notably, shared environments had no significant influence on NPD in any of these studies.

— Lu & Cai, 2018

According to neurogeneticist Kevin Mitchell, a lack of influence from the shared environment indicates that the non-shared environmental influence may be largely non-social, perhaps reflecting innate processes such as randomness in brain growth.

Pathophysiology

Neuroscientists have also studied the brains of people with NPD using structural imaging technology. A 2021 review concluded the most consistent finding among NPD patients is lowered gray matter volume in the medial prefrontal cortex, previously associated with self-enhancement tendencies. Studies of the occurrence of narcissistic personality disorder identified structural abnormalities in the brains of people with NPD, specifically, a lesser volume of gray matter in the left, anterior insular cortex. The results of a 2015 study associated the condition of NPD with a reduced volume of gray matter in the prefrontal cortex. It has been suggested that empathic dysfunction and selfish behaviour in NPD may result from dysfunction in the brain's salience network (SN; consisting of the anterior insula and cingulate cortices), which switches between internally- and externally-focused cognition, to inhibit the default mode network (DMN), involved in self-related information-processing, during social interactions resulting in continued self-focus even when interacting with distressed others. Consonantly, excessive selfishness in NPD appears to be related to decreased ability of the cingulate cortex to track motivational conflict between self-gain and other-pain.

Grandiose and vulnerable expressions of NPD appear to relate differently to brain structure and function. Specifically, NPD patients with grandiose features show enhanced while those vulnerable features show reduced local efficiency in the DMN. Vulnerable cases of NPD also appear to show increased oxidative stress.

Other aspects

Evolutionary models of NPD have also been proposed. According to psychologist Marco Del Giudice, cluster B traits including NPD, predict increased mating success and fertility. NPD could potentially be an adaptive evolutionary phenomenon, though a risky one that can sometimes result in social rejection and failure to reproduce. Another proposal is that NPD may result from an excess of traits which are only adaptive in moderate amounts (leadership success increases with moderate degrees of narcissism, but declines at the high end of narcissism).

Research on NPD is limited, because patients are hard to recruit for study. The cause of narcissistic personality disorder requires further research.

Management

Treatment for NPD is primarily psychotherapeutic; there is no clear evidence that psychopharmacological treatment is effective for NPD, although it can prove useful for treating comorbid disorders. Psychotherapeutic treatment falls into two general categories: psychoanalytic/psychodynamic and cognitive behavioral. Psychoanalytic therapies include schema therapy, transference focused psychotherapy, mentalization-based treatment and metacognitive psychotherapy. Cognitive behavioral therapies include cognitive behavioral therapy and dialectal behavior therapy. Formats also include group therapy and couples therapy. The specific choice of treatment varies based on individual presentations.

Management of narcissistic personality disorder has not been well studied, however many treatments tailored to NPD exist. Therapy is complicated by the lack of treatment-seeking behavior in people with NPD, despite mental distress. Additionally, people with narcissistic personality disorders have decreased life satisfaction and lower qualities of life, irrespective of diagnosis. People with NPD often present with comorbid mental disorders, complicating diagnosis and treatment. NPD is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they often express seeking relief from a comorbid mental disorder, including major depressive disorder, a substance use disorder (drug addiction), or bipolar disorder.

Prognosis

As of 2020, no treatment guidelines exist for NPD and no empirical studies have been conducted on specific NPD groups to determine efficacy for psychotherapies and pharmacology. Though there is no known single cure for NPD, there are some things one can do to lessen its symptoms. Medications such as antidepressants, which treat depression, are commonly prescribed by healthcare providers; mood stabilizers to reduce mood swings and antipsychotic drugs to reduce the prevalence of psychotic episodes.

The presence of NPD in patients undergoing psychotherapy for the treatment of other mental disorders is associated with slower treatment progress and higher dropout rates. In this therapy, the goals often are examining traits and behaviors that negatively affect life, identifying ways these behaviors cause distress to the person and others, exploring early experiences that contributed to narcissistic defenses, developing new coping mechanisms to replace those defenses, helping the person see themselves and others in more realistic and nuanced ways, rather than wholly good or wholly bad, identifying and practicing more helpful patterns of behavior, developing interpersonal skills, and learning to consider the needs and feelings of others.

Epidemiology

As of 2018, overall prevalence is estimated to range from 0.8% to 6.2%. In 2008 under the DSM-IV, lifetime prevalence of NPD was estimated to be 6.2%, with 7.7% for men and 4.8% for women, with a 2015 study confirming the gender difference. In clinical settings, prevalence estimates range from 1% to 15%. The same 2008 study presented a significantly higher prevalence of NPD among Black men and women and Hispanic women, younger adults, and separated/divorced/widowed and never married adults.  The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders.

History

The term "narcissism" comes from the first century (written in the year 8 AD) narrative poem the Metamorphoses by the Roman poet Ovid. Book III of the Metamorphoses features a myth about two main characters, Narcissus and Echo. Narcissus is a handsome young man who spurns the advances of many potential lovers. When Narcissus rejects Echo, a nymph cursed to only echo the sounds that others made, the goddess Nemesis punishes him by making him fall in love with his own reflection in a pool of water. When Narcissus discovers that the object of his love cannot love him back, he slowly pines away and dies.

The concept of excessive selfishness has been recognized throughout history. In ancient Greece, the concept was understood as hubris. It is only since the late 1800s that narcissism has been defined in psychological terms:

  • Havelock Ellis (1898) was the first psychologist to use the term when he linked the myth to the condition in one of his patients.
  • Sigmund Freud (1905–1953) used the terms "narcissistic libido" in his Three Essays on the Theory of Sexuality.
  • Ernest Jones (1913/1951) was the first to construe extreme narcissism as a character flaw.
  • Robert Waelder (1925) published the first case study of narcissism. His patient was a successful scientist with an attitude of superiority, an obsession with fostering self-respect, and a lack of normal feelings of guilt. The patient was aloof and independent from others and had an inability to empathize with others' situations, and was selfish sexually. Waelder's patient was also overly logical and analytical and valued abstract intellectual thought (thinking for thinking's sake) over the practical application of scientific knowledge.

Narcissistic personality was first described by the psychoanalyst Robert Waelder in 1925. The term narcissistic personality disorder (NPD) was coined by Heinz Kohut in 1968. Waelder's initial study has been influential in the way narcissism and the clinical disorder Narcissistic personality disorder are defined today

Freudianism and psychoanalysis

Much of the early history of narcissism and NPD originates from psychoanalysis. Regarding the adult neurotic's sense of omnipotence, Sigmund Freud said that "this belief is a frank acknowledgement of a relic of the old megalomania of infancy"; and concluded that: "we can detect an element of megalomania in most other forms of paranoic disorder. We are justified in assuming that this megalomania is essentially of an infantile nature, and that, as development proceeds, it is sacrificed to social considerations."

Narcissistic injury and narcissistic scar are terms used by Freud in the 1920s. Narcissistic wound and narcissistic blow are other, almost interchangeable, terms. When wounded in the ego, either by a real or a perceived criticism, a narcissistic person's displays of anger can be disproportionate to the nature of the criticism suffered; but typically, the actions and responses of the NPD person are deliberate and calculated. Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable.

In The Psychology of Gambling (1957), Edmund Bergler considered megalomania to be a normal occurrence in the psychology of a child, a condition later reactivated in adult life, if the individual takes up gambling. In The Psychoanalytic Theory of Neurosis (1946), Otto Fenichel said that people who, in their later lives, respond with denial to their own narcissistic injury usually undergo a similar regression to the megalomania of childhood.

Narcissistic supply

Narcissistic supply was a concept introduced by Otto Fenichel in 1938, to describe a type of admiration, interpersonal support, or sustenance drawn by an individual from his or her environment and essential to their self-esteem. The term is typically used in a negative sense, describing a pathological or excessive need for attention or admiration that does not take into account the feelings, opinions, or preferences of other people.

Narcissistic rage

The term narcissistic rage was a concept introduced by Heinz Kohut in 1972. Narcissistic rage was theorised as a reaction to a perceived threat to a narcissist's self-esteem or self-worth. Narcissistic rage occurs on a continuum from aloofness, to expressions of mild irritation or annoyance, to serious outbursts, including violent attacks.

Narcissistic rage reactions are not necessarily limited to narcissistic personality disorder. They may also be seen in catatonic, paranoid delusion, and depressive episodes. It was later suggested that narcissistic people have two layers of rage; the first layer of rage being directed constant anger towards someone else, with the second layer being self-deprecating.

Object relations

In the second half of the 20th century, in contrast to Freud's perspective of megalomania as an obstacle to psychoanalysis, in the US and UK Kleinian psychologists used the object relations theory to re-evaluate megalomania as a defence mechanism. This Kleinian therapeutic approach built upon Heinz Kohut's view of narcissistic megalomania as an aspect of normal mental development, by contrast with Otto Kernberg's consideration of such grandiosity as a pathological distortion of normal psychological development.

To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed individual who passes blame by psychological projection and is intolerant of contradictory views and opinions; is apathetic towards the emotional, mental, and psychological needs of other people; and is indifferent to the negative effects of their behaviors, whilst insisting that people should see them as an ideal person. The merging of the terms "inflated self-concept" and "actual self" is evident in later research on the grandiosity component of narcissistic personality disorder, along with incorporating the defence mechanisms of idealization and devaluation and of denial.

Comparison to other personality disorders

NPD mainly overlaps with Borderline Personality Disorder (BPD), Antisocial Personality Disorder (ASPD), and Histrionic Personality Disorder (HPD) as all are "Cluster B" disorders. Cluster B personality disorders are characterized by impulsivity, an inability to regulate emotions, and a difficulty maintaining social relationships. Because these personality disorders share symptoms and behaviors with NPD, many are also comorbid with NPD.

Borderline Personality Disorder is characterized as having an instability in emotions, relationships, and self image. The presence of BPD is also highly associated with traits such as grandiosity, lack of empathy, and praise-seeking behaviors which are characteristic of NPD. Research has shown that BPD does, in fact, have high comorbidity rates with NPD.

Antisocial Personality Disorder is similarly characterized by impulsivity and a lack of empathy, but also by a disregard for the rights of others and a tendency to manipulate others. Additionally, both antisociality and narcissism are heavily correlated with psychopathy, further suggesting an overlap between the two.

Controversy

The extent of controversy about narcissism was on display when the committee on personality disorders for the 5th Edition (2013) of the Diagnostic and Statistical Manual of Mental Disorders recommended the removal of Narcissistic Personality from the manual. A contentious three-year debate unfolded in the clinical community with one of the sharpest critics being John Gunderson, who led the DSM personality disorders committee for the 4th edition of the manual.

The American Psychiatric Association's (APA) formulation, description, and definition of narcissistic personality disorder, as published in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed., Text Revision (DSM-IV-TR, 2000), was criticised by clinicians as inadequately describing the range and complexity of the personality disorder that is NPD. That it is excessively focused upon "the narcissistic individual's external, symptomatic, or social interpersonal patterns – at the expense of ... internal complexity and individual suffering", which reduced the clinical utility of the NPD definition in the DSM-IV-TR.

In revising the diagnostic criteria for personality disorders, the work group for the list of "Personality and Personality Disorders" proposed the elimination of narcissistic personality disorder (NPD) as a distinct entry in the DSM-5, and thus replaced a categorical approach to NPD with a dimensional approach, which is based upon the severity of the dysfunctional-personality-trait domains. Clinicians critical of the DSM-5 revision characterized the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist", which is of limited usefulness in clinical practice. Despite the reintroduction of the NPD entry, the APA's re-formulation, re-description, and re-definition of NPD, towards a dimensional view based upon personality traits, remains in the list of personality disorders of the DSM-5.

A 2011 study concluded that narcissism should be conceived as personality dimensions pertinent to the full range of personality disorders, rather than as a distinct diagnostic category. In a 2012 literature review about NPD, the researchers concluded that narcissistic personality disorder "shows nosological inconsistency, and that its consideration as a trait domain needed further research would be strongly beneficial to the field." In a 2018 latent structure analysis, results suggested that the DSM-5 NPD criteria fail to distinguish some aspects of narcissism relevant to diagnosis of NPD and subclinical narcissism.

  • Suzanne Stone-Maretto, Nicole Kidman's character in the film To Die For (1995), wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she "was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder... had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder".
  • Jay Gatsby, the eponymous character of F. Scott Fitzgerald's novel The Great Gatsby (1925), "an archetype of self-made American men seeking to join high society", has been described by English professor Giles Mitchell as a "pathological narcissist" for whom the "ego-ideal" has become "inflated and destructive" and whose "grandiose lies, poor sense of reality, sense of entitlement, and exploitive treatment of others" conspire toward his own demise.
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