What Is the Relationship Between Narcissistic Personality Disorder and Substance Use?

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Substance use disorder (SUD) commonly occurs with other mental health disorders. Personality disorders often share the trait of impulsivity with SUD. Narcissistic personality disorder (NPD) is a type of personality disorder that commonly co-occurs with SUD. This can complicate treatments as NPD symptoms will affect SUD and vice versa. Both disorders must be treated simultaneously in order for treatment to be effective. Understanding the signs and symptoms of NPD can help someone struggling with the disorder manage their NPD and SUD symptoms at the same time and help them heal.

Cluster 'B' Personality Disorders

Psychiatrists can have difficulties diagnosing NPD because of its shared similarities with other personality disorders. These disorders are defined by the Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5) as “Cluster B” personality disorders and include:

  • Borderline personality disorder (BPD)
  • Antisocial personality disorder  (APD)
  • Histrionic personality disorder (HPD)
  • Major depressive disorder (MDD)
  • Obsessive-compulsive disorder (OCD)
  • Substance-induced mood disorder (SIMD)

“Cluster B” personality disorders are associated with dramatic, over-emotional, and unpredictable cognitions or behaviors. These behaviors can be harmful to a person's interpersonal relationships and career opportunities.

Diagnosis Criteria

There are two identified subtypes of NPD. The first NPD subtype is a sense of grandioseness, which is characterized by aggression, boldness, lack of empathy, and the exploitation of others. Vulnerability is considered the second subcategory of NPD, which is characterized by hypersensitivity and defensiveness. Typically men are more likely to be diagnosed with NPD than women. 

To be diagnosed with NPD, somebody needs to identify with one of the following five symptoms:

  • Have a sense of grandiose and self-importance (exaggerating achievements, expecting to be recognized as superior without putting the work in to do so)
  • Believe they're “special” and can only be understood by other special people or institutions
  • Obsessing over fantasies of success, power, brilliance, beauty, or perfect love
  • Need for excessive admiration
  • A sense of entitlement (unreasonable expectations for favorable treatment)
  • Jealousy of others or believing others are jealous of them
  • Displayed arrogance in both behavior and attitude
  • A lack of empathy or unwillingness to meet others' needs

The more aggressive presenting symptoms are in a person with NPD, the more severe the disorder is classified. NPD can lead to unstable interpersonal relationships, higher risk for suicide, attention seeking, and low-self esteem.

Identifying Narcissistic Personality Disorder

Some similarities between NPD and other personality disorders include the appearance of hypomanic/manic symptoms (present in BPD), impulsivity (present in BPD), and anhedonia (present in dysthymia depression). NPD is most similar to antisocial disorder because both disorders are associated with a lack of empathy. However, NPD is not associated with a lack of moral understanding like antisocial personality disorder. 

Co-Occurring Disorders

Personality disorders are highly correlated with other personality and SUD disorders. About 40.6% of people diagnosed with NPD have SUD. People with NPD are also more likely to have anxiety and other mood disorders.

Risk Factors of Narcissistic Personality Disorder

Risks for NPD usually occur in a person's developmental stages of early childhood. Some risk factors include a genetic predisposition to the disorder, insensitive parenting, reduced tolerance to stress, aggressive personality, being rejected as a child, and affect dysregulation. Similar factors can also put a person at risk for developing SUD.

Treatment for Narcissistic Personality Disorder

There are no formal treatment options for NPD. Currently, there aren't any FDA-approved medications or psychotherapy options specifically for NPD. However, therapies and medications approved to treat other mental health disorders can be used to treat NPD symptoms. 

People with NPD are more likely to be resistant to psychotherapy and experience negative countertransference or therapist redirection of the client's projections. Due to their beliefs of being “special,” a person with NPD might feel like they're being mistreated or criticized during a psychotherapy session.

NPD treatments have a higher rate of self-terminating treatment. Some treatments that are recommended to curb disengaging behaviors during therapy include the FRAMES technique, transference-focused psychotherapy, and schema-focused therapy.

FRAMES Technique

This therapeutic technique focuses on the therapist-client relationship. FRAMES stands for feedback, responsibility, advice, the menu of strategies, empathy, and self-efficacy. Using these six components, the FRAMES technique aims to promote behavioral change in the client.

Transference-Focused Psychotherapy

This type of psychotherapy was developed to treat personality disorders. Specifically, Otto Kernber created the transference-focused psychotherapy (TFP) approach to benefit people with BPD and NPD. Transference is when a client projects their feelings onto a therapist. TFP uses transference to deal with destructive behaviors or ideas as they occur in therapy instead of using outside situations.

Schema-Focused Therapy

Developed to treat different types of personality disorders, schema-focused therapy is a combination of cognitive-behavioral therapy (CBT), attachment theory, and gestalt therapy. This type of therapy focuses on the development of symptoms, the parent-psychotherapist relationship, learning adaptively to meet needs, and reprocessing early childhood traumatic memories.

Narcissistic personality disorder is commonly dually diagnosed with substance use disorder. Understanding the signs and symptoms of NPD can help you manage your substance use and mental health disorder symptoms. Pathways Recovery Center uses empathy and compassion to connect with clients and create a treatment plan that will meet their recovery needs. We offer treatment for a variety of co-occurring disorders, including NPD. Our mental health professionals are here to help you find the right combinations of treatment so you can take recovery one day at a time. If you or someone you know is struggling with substance use, call Pathways Recovery Center at (888) 771-0966 to learn how we can meet you where you are in recovery.

Clinically reviewed by 

Moses Nasser
Dr. Moses Nasser, a double board-certified physician in Family Medicine and Addiction Medicine, with expertise in holistic healing, addiction medicine, and psychiatric care, holds an X-waiver to prescribe buprenorphine and has extensive experience in mindfulness-based customer service and medication-assisted treatment.

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