C<\/span>an you think of a narcissist? Some people might picture Donald Trump, perhaps, or Elon Musk, both of whom are often labeled as such on social media. Or maybe India’s prime minister, Narendra Modi, who once wore a pinstripe suit<\/a> with his own name woven in minute gold letters on each stripe over and over again.<\/p>\n But chances are you’ve encountered a narcissist, and they looked nothing like Trump, Musk or Modi. Up to 6 percent of the U.S. population, mostly men, is estimated to have had narcissistic personality disorder during some period of their lives. And the condition manifests in confoundingly different ways. People with narcissism \u201cmay 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,\u201d according to a review paper on diagnosing the disorder.<\/p>\n Clinicians note several dimensions on which narcissists vary. They may function extremely well, with successful careers and vibrant social lives, or very poorly. They may (or may not) have other disorders, ranging from depression to sociopathy. And although most people are familiar with the \u201cgrandiose\u201d version of narcissism\u2014as displayed by an arrogant and pompous person who craves attention\u2014the disorder also comes in a \u201cvulnerable\u201d or \u201ccovert\u201d form, where individuals suffer from internal distress and fluctuations in self-esteem. What these seeming opposites have in common is an extreme preoccupation with themselves.<\/p>\n Most psychologists who treat patients say that grandiosity and vulnerability coexist in the same individual, showing up in different situations. Among academic psychologists, however, many contend that these two traits do not always overlap. This debate has raged for decades without resolution, most likely because of a conundrum: vulnerability is almost always present in a therapist’s office, but individuals high in grandiosity are unlikely to show up for treatment. Psychologist Mary Trump deduces, from family history and close observation, that her uncle, Donald Trump, meets the criteria for narcissistic as well as, probably, antisocial personality disorder, at the extreme end of which is sociopathy. But \u201ccoming up with an accurate and comprehensive diagnosis would require a full battery of psychological and neuropsychological tests that he’ll never sit for,\u201d she notes in her book on the former president.<\/p>\n Now brain science is contributing to a better understanding of narcissism. It’s unlikely to resolve the debate, but preliminary studies are coming down on the side of the clinicians: vulnerability indeed seems to be the hidden underside of grandiosity.<\/p>\n Tessa, a 25-year-old who now lives in California, has sometimes felt on top of the world. \u201cI would wake up every day and go to college believing I was going to be a famous singer and that my life was going to be fantastic,\u201d she recalls. \u201cI thought I could just keep perfecting myself and that someday I would end up as this amazing person surrounded by this amazing life.\u201d<\/p>\n But she also hit severe emotional lows. One came when she realized that the fabulous life she imagined might never come to be. \u201cIt was one of the longest periods of depression I’ve ever gone through,\u201d Tessa tells me. \u201cI became so bitter, and I’m still working through it right now.\u201d<\/p>\n That dissonance between fantasy and reality has spilled into her relationships. When speaking to other people, she often finds herself bored\u2014and in romantic partnerships, especially, she feels disconnected from both her own and her partner’s emotions. An ex-boyfriend, after breaking up, told her she’d been oblivious to the hurt she caused him by exploding in rage when he failed to meet her expectations. \u201cI told him, \u2018Your suffering felt like a cry in the wind\u2014I didn’t know you were feeling that way\u2019 \u2026 all I could think about was how betrayed I felt,\u201d she says. It upset her to see him connect with other people; she reacted by degrading his friends and trying to stop him from meeting them. And she hated him admiring other people because it made her question whether he’d continue to see her as admirable.<\/p>\n Not being able to live the idealized versions of herself\u2014which include visions of being surrounded by friends and fans who love and idolize her for her beauty and talent\u2014leaves Tessa profoundly distressed. \u201cSometimes I simultaneously feel above everything, above life itself, and also like a piece of trash on the side of the road,\u201d she says. \u201cI feel like I’m constantly trying to hide and cover things up. I’m constantly stressed and exhausted. I’m also constantly trying to build an inner self so I don’t have to feel that way anymore.\u201d After her parents suggested therapy, Henderson was diagnosed with narcissistic personality disorder (NPD) in 2023.<\/p>\n What makes narcissism particularly complex is that it may not always be dysfunctional. \u201cBeing socially dominant, being achievement-striving and focused on improving one’s own lot in life by themselves are not all that problematic and tend to be valued by Western cultures,\u201d notes Aidan Wright, a psychologist at the University of Michigan.<\/p>\n Elsa Ronningstam, a clinical psychologist at McLean Hospital in Massachusetts, says the relatively functional variety of narcissism includes having, when things are going well, a positive view of oneself and a drive to preserve one’s own well-being, while still being able to maintain close relationships with others and tolerate divergences from an idealized version of oneself. Then there is \u201cpathological\u201d narcissism, characterized by an inability to maintain a steady sense of self-esteem. Those with this condition protect an inflated view of themselves at the expense of others and\u2014when that view is threatened\u2014experience anger, shame, envy and other negative emotions. They can go about living relatively normal lives and act out only in certain situations. Narcissistic personality disorder is a subtype of pathological narcissism in which someone has persistent, long-term issues. It often occurs along with other conditions, such as depression, bipolar disorder, borderline personality or antisocial personality disorder.<\/p>\n In the ancient Greek tale of Narcissus, a young hunter, admired for his unmatched beauty, spurns many who love and pursue him. Among them is Echo, an unfortunate nymph\u2014who, after pulling a trick on one of the gods, has lost her ability to speak except for words already spoken by another. Though initially entranced by a voice that mirrored his own, Narcissus ultimately rejects Echo’s embrace.<\/p>\n The god Nemesis then curses Narcissus, causing him to fall in love with his own reflection in a pool of water. Narcissus becomes hopelessly infatuated with his own image, which he believes to be another beautiful being, and becomes distraught when he finds it cannot reciprocate his affection. In some versions of the story, he wastes away before his own likeness, dying of thirst and starvation.<\/p>\n In the 1960s and 1970s psychoanalysts Heinz Kohut and Otto Kernberg sketched what’s now known as the \u201cmask model\u201d<\/a> of narcissism. It postulated that grandiose traits such as arrogance and assertiveness conceal feelings of insecurity and low self-esteem. The 1980 edition of the Diagnostic and Statistical Manual of Mental Disorders<\/em> (DSM), the main reference used by clinicians in the U.S., reflected this insight by including vulnerable features in its definition of NPD, although it emphasized the grandiose ones. But some psychiatrists contended that the vulnerability criteria overlapped too much with those of other personality disorders. Borderline personality disorder (BPD), in particular, shares with NPD characteristics of vulnerability such as difficulty managing emotions, sensitivity to criticism, and unstable relationships. Subsequent versions of the DSM therefore placed even more weight on grandiose features\u2014such as an exaggerated sense of self-importance, a preoccupation with fantasies of unlimited success and power, an excessive need for admiration and a lack of empathy.<\/p>\n In the early 2000s Aaron Pincus, a clinical psychologist at Pennsylvania State University, noticed that this focus on grandiosity did not accurately represent what he was seeing in narcissistic patients. \u201cIt was completely ignoring what typically drives patients to come to therapy, which is vulnerability and distress,\u201d Pincus says. \u201cThat got me on a mission to get us more calibrated in the science.\u201d In a 2008 review<\/a>, Pincus and his colleagues discovered enormous variability in how mental health practitioners were conceptualizing NPD, with dozens of labels for the ways in which narcissism expressed itself. But there was also a common thread: descriptions of both grandiose and vulnerable ways in which the disorder showed up.<\/p>\n Since then, researchers have found that both dimensions of narcissism are linked to<\/a> what psychologists call \u201cantagonism,\u201d which includes selfishness, deceitfulness and callousness. But grandiosity is associated with being assertive and attention seeking, whereas vulnerability tends to involve neuroticism and suffering from anxiety, depression and self-consciousness. Vulnerable narcissism also more often goes along with self-harm (which can include hairpulling, cutting, burning and related behaviors that are also found in people with BPD) and risk of suicide than the grandiose form.<\/p>\n The two manifestations of narcissism are also linked to different kinds of problems in relationships. In grandiose states, people with NPD may be more vindictive and domineering toward others, whereas in vulnerable phases they may be more withdrawn and exploitable.<\/p>\n Jacob Skidmore, a 23-year-old with NPD who runs accounts as The Nameless Narcissist on several social media platforms, says he often flips from feeling grandiose to vulnerable, sometimes multiple times a day. If he’s getting positive attention from others or achieves his goals, he experiences grandiose \u201chighs\u201d when he feels confident and secure. \u201cIt’s almost a euphoric feeling,\u201d he says. But when these sources of ego boosts\u2014something he refers to as \u201cself-esteem juice\u201d\u2014dry up, he finds himself slipping into lows when an overwhelming feeling of shame might stop him from even leaving his home. \u201cI’m afraid to go outside because I feel like the world is going to judge me or something, and it’s painful,\u201d Skidmore says. \u201cIt feels like I’m being stabbed in the chest.\u201d<\/p>\n The desire to fill up on self-esteem has driven many of Skidmore’s more grandiose behaviors\u2014whether it was making himself the de facto leader of multiple social groups where he referred to himself as \u201cthe Emperor\u201d and punished those who angered him or forging relationships purely for the sake of boosting his self-esteem. Skidmore hasn’t always presented himself in grandiose ways: when he was younger, he was much more outwardly sensitive and insecure. \u201cI remember looking in the mirror and thinking about how disgusting I was and how much I hated myself,\u201d he tells me.<\/p>\n Clinicians<\/a>‘ evaluations, as well as studies in the wider population, support the idea that narcissists oscillate between these two states. In recent surveys, Wright and his graduate student Elizabeth Edershile asked hundreds of undergraduate students and community members to complete assessments that measured their levels of grandiosity and vulnerability multiple times a day over several days. They found that whereas vulnerability and grandiosity do not generally coexist in the same moment, people who are overall more grandiose also undergo periods of vulnerability\u2014whereas those who are generally more vulnerable don’t experience much grandiosity. Some studies suggest that the overlap may depend on the severity of the narcissism: clinical psychologist Emanuel Jauk of the Medical University of Graz in Austria and his colleagues found in surveys that vulnerability may be more likely to appear in highly grandiose individuals.<\/p>\n
To Diana Diamond, a clinical psychologist at the City University of New York, such findings suggest that the mask model is too simple. \u201cThe picture is much more complex\u2014vulnerability and grandiosity exist in dynamic relation to each other, and they fluctuate according to what the individual is encountering in life, the stage of their own development.\u201d<\/p>\n But Josh Miller, a psychologist at the University of Georgia, and others entirely reject<\/a> the idea that grandiose individuals are concealing a vulnerable side. Although grandiose people may sometimes feel vulnerable, that vulnerability isn’t necessarily linked to insecurities, Miller argues. \u201cI think they feel really angry because what they cherish more than anything is a sense of superiority and status\u2014and when that’s called into question, they’re going to lash back,\u201d he adds. Psychologist Donald Lynam of Purdue University agrees: \u201cI think people can be jerks for lots of reasons\u2014they could simply think they’re better than others or be asserting status or dominance\u2014it’s an entirely different motivation, and I think that motivation has been neglected.\u201d<\/p>\n These differences in perspective may arise because different types of psychologists are studying different populations. In a 2017 study, researchers surveyed 23 clinical psychologists and 22 social and\/or personality psychologists (who do not work with patients) and found that although both groups viewed grandiosity as an essential aspect of narcissism, clinical psychologists were slightly more likely to view vulnerability as being at its core<\/a>.<\/p>\n Most narcissists who seek help are generally more vulnerable, Miller notes: \u201cThese are wounded people who come in to seek treatment for their wounds.\u201d To him, that means clinics might not be the best place to study narcissism\u2014at least not its grandiose aspect. It’s \u201ca little bit like trying to learn about a lion’s behavior in a zoo,\u201d he says.<\/p>\n The unwillingness to seek therapy is especially true of \u201cmalignant narcissists,\u201d who, in addition to the usual characteristics, exhibit antisocial and psychopathic features such as lying chronically or enjoying inflicting pain or suffering on others.<\/p>\n Marianne (whose name has been changed for privacy) recalls her father, a brilliant scientist whom her own therapist deemed a malignant narcissist after reading the voluminous letters he’d sent over the years. (He never sought therapy.) It was \u201call about constant punishment,\u201d Marianne says. He implemented stringent rules, such as putting a strict time limit on how long their family of five children could use the bathroom during long road trips. If, by the time he’d filled the tank, everyone hadn’t returned to the car, he’d leave. On one occasion, Marianne was abandoned at a gas station when she couldn’t make it back on time. \u201cThere was [hardly] a day without that kind of drama\u2014one person being isolated, punished, humiliated, being called out,\u201d she remembers. \u201cIf you cried, he’d say you’re being histrionic. He didn’t associate that crying with his actions; he thought it was performative.\u201d<\/p>\n Her father also pitted her siblings and their mother against one another to prevent them from forging close connections\u2014and he constantly looked for flaws in those around him. Marianne recalls dinner parties at home where her father spent hours trying to pinpoint weaknesses among the other husbands and to hurt couples’ opinions of each other. When Marianne brought home boyfriends, her father challenged them and tried to prove that he was superior. And despite being a dazzling academic who easily charmed people when they first met, he got fired time and time again because of conflicts at the universities where he worked. \u201cIt was all about one-upmanship,\u201d she says. \u201cHis impulse to destroy anything that was shiny, that was popular, that was loved\u2014it overwhelmed everything else.\u201d<\/p>\n Malignant narcissists often pose the greatest challenge for therapists\u2014and they may be particularly dangerous in leadership positions, Diamond notes. They can have deficient moral functioning while exerting an enormous amount of influence on followers. \u201cI think this is something that’s going on right now, with the rise of authoritarianism worldwide,\u201d she adds.<\/p>\n Research with identical and nonidentical twins suggests that narcissism may be at least partially genetically heritable<\/a>, but other studies indicate that dysfunctional parenting might also play a significant role. Grandiosity may derive from caregivers holding inflated views about their child’s superiority, whereas vulnerability may originate in having a caregiver who was cold, neglectful, abusive or invalidating. Complicating matters, some studies find overvaluation also plays a role in vulnerable narcissism, whereas others fail to find a link between parenting and grandiosity. \u201cChildren who develop NPD may have felt seen and appreciated when they achieved or behaved in a certain way that satisfied a caregiver’s expectations but ignored, dismissed or scolded when they failed to do so,\u201d Ronningstam summarizes in her guide to the disorder.<\/p>\n Skidmore attributes his own NPD to both genes and painful childhood experiences. \u201cI’ve never met a narcissist who has not had trauma,\u201d he says. \u201cPeople just use love as this carrot on a stick [that] they hang above your head, and they tell you to behave or they’ll take it away. And so I have this mindset of, \u2018Well then, screw it! I don’t need love. I can take admiration, achievements, my intelligence\u2014you can’t take those things away from me.\u2019<\/p>\n Many researchers nonetheless say a lot more work is needed to determine what role, if any, parenting plays. Miller points out that most research to date of grandiosity, in particular, has found small effects. Further, the work was done retrospectively\u2014asking people to recall their past experiences\u2014rather than prospectively to see how early life experiences affect outcomes.<\/p>\n There is another way to study what is going on with a narcissist, however: look inside. In a study published in 2015, researchers at the University of Michigan recruited 43 boys aged 16 or 17 and asked them to fill out the Narcissism Personality Inventory, a questionnaire that primarily measures grandiose traits. The teenagers then played Cyberball, a virtual ball-tossing game, while their brain activity was measured using functional magnetic resonance imaging (fMRI), a noninvasive neuroimaging method that enables researchers to observe the brain at work.<\/p>\n Cyberball tests how well people deal with social exclusion. Participants are told that they’re playing with two other people, although they are actually playing with a computer. In some rounds, the virtual players include the human participant; in others, the virtual players begin by tossing the ball to everyone but later pass it just between themselves\u2014cutting the participant out of the game.<\/p>\n The teenagers with higher levels of grandiose narcissism turned out to have greater activity in the so-called social pain network than those with lower scores. This network is a collection of brain regions\u2014including parts of the insula and the anterior cingulate cortex\u2014that prior studies had found were associated with distress in the face of social exclusion. Interestingly, the researchers did not find differences in the boys’ self-reports of distress. In another revealing fMRI study, Jauk and his Graz colleagues found that men (but not women) with higher levels of grandiose narcissism showed more activity in parts of the anterior cingulate cortex associated with negative emotions and social pain when viewing images of themselves compared with images of close friends or strangers.<\/p>\n The bodies of narcissists bear evidence of elevated stress. Studies indicate that men with more narcissism have higher levels of the stress hormone cortisol than those with less narcissism. In a 2020 study, Royce Lee, a psychiatrist at the University of Chicago, and his colleagues reported that people with NPD\u2014as well as those with BPD\u2014have greater concentrations of molecules associated with oxidative stress (a stress response seen at the cellular level) in their blood.<\/p>\n Such findings suggest that \u201cvulnerability is always there but maybe not always expressed,\u201d Jauk says. \u201cAnd under particular circumstances, such as in the lab, you can observe signs of vulnerability at a physiological level, even if people say, \u2018I don’t have vulnerability.\u2019\u201d He adds, however, that these studies are far from the last word on the matter: many of them have a small number of subjects, and some have reported contradicting findings. Follow-up studies, ideally with a larger number of individuals, are needed to validate their results. The neuroscience of narcissism \u201cis incredibly interesting, but at the same time, I’m very hesitant to interpret any of these results,\u201d says Mitja Back, a psychologist at the University of M\u00fcnster in Germany.<\/p>\n To date, there have been no randomized clinical trials for treatments specific for narcissistic personality disorder. Clinicians have, however, begun to adapt psychotherapies that have proved to be effective in other related conditions, such as borderline personality disorder. Treatments currently used include \u201cmentalization,\u201d which aims to help individuals make sense of both their own and others’ mental states, and \u201ctransference,\u201d which focuses on enhancing a person’s ability to self-reflect, take the perspective of others and regulate their emotions. But there is still a dire need for effective treatments.<\/p>\n \u201cPeople with pathological narcissism and narcissistic personality disorder have a reputation of not changing or dropping off from treatment,\u201d Ronningstam says. \u201cInstead of blaming that on them, the clinicians and researchers need to really further develop strategies that can be adjusted to the individual difference\u2014and at the same time to focus on and promote change.\u201d<\/p>\n Since discovering she has NPD, Tessa has started a YouTube channel called SpiritNarc<\/a> where she posts videos about her experiences and perspectives on narcissism. \u201cI really want the world to understand [narcissism],\u201d she says. \u201cI’m so sick of the narrative that’s going around\u2014people see the outside behavior and say, \u2018This means these people are awful.\u2019\u201d What these people don’t see, she adds, is the suffering that lies below the surface.<\/p>\n<\/div>\nFantasy or Reality?<\/h2>\n
The 21st-century Narcissus<\/h2>\n
Self-Esteem Juice<\/h2>\n
![\"Graphic](\"https:\/\/static.scientificamerican.com\/sciam\/assets\/Image\/2023\/saw0923Kwon31_d.jpg\"\/)
<\/picture><\/div>\n
\n
\n<\/figure>\nAn Adverse Childhood?<\/h2>\n
Toward Treatments<\/h2>\n