Understanding Narcissism: Part 3 | How Is Narcissistic Personality Disorder (NPD) Diagnosed?

NPD is a recognised mental health diagnosis that requires a comprehensive clinical assessment. It isn't diagnosed simply because someone is selfish, outspoken, difficult in relationships or behaves arrogantly.

So, how is NPD actually diagnosed?

NPD is a personality disorder. Diagnosis involves assessing a person's longstanding patterns of thinking, feeling and behaving, particularly how they see themselves and relate to other people.

Your MM Psychologist will review whether there is a persistent pattern involving characteristics such as grandiosity, a strong need for admiration, entitlement and difficulties with empathy. The most important word here is pattern. All of us have moments when we want recognition. All of us can become defensive when criticised. All of us have occasionally behaved selfishly. That doesn't mean we have a personality disorder. Your MM Psychologist is assessing whether these characteristics are pervasive, longstanding and causing significant difficulties in the person's life or relationships.

What does an assessment look for?

A psychologist assessing for Narcissistic Personality Disorder (NPD) is not simply looking for whether someone has behaved narcissistically. Instead, the assessment considers the overall pattern of personality functioning, including how the person experiences themselves, relates to others, manages their self-esteem and responds when that self-image is challenged.

Some of the areas explored may include:

Sense of self

The psychologist may explore how the person views themselves, including their strengths, limitations, achievements and sense of importance. For example, can they acknowledge both their successes and their shortcomings, or is their self-esteem heavily dependent on being seen as exceptional, successful or superior?

A person might respond to constructive feedback with, “Ah I hadn't thought about it that way. I can see that I could have handled that better.” Alternatively, they may experience relatively ordinary feedback as a significant threat to their self-worth and respond with intense defensiveness or a need to re-establish their status or competence.

Relationships

The Psychological assessment considers how the person typically relates to other people and whether their relationships are characterised by reciprocity, mutuality and respect. For example, when a partner has a problem, can the person become interested in their partner's experience and make space for their needs? Or does the conversation consistently return to their own needs, achievements, grievances or expectations?

The Psychologist will also consider whether these patterns occur across different relationships, such as with partners, family members, friends and colleagues, rather than occurring only within one particularly difficult relationship.

Empathy

Empathy involves the capacity to recognise and understand another person's emotional experience and perspective. It does not mean agreeing with someone or accepting their interpretation of an event. For example, a person might say, “I don't remember it happening that way, but I can understand why you felt hurt.”

The Psychologist may explore whether the person can consistently recognise another person's feelings and perspective, particularly when doing so requires them to put their own needs or viewpoint to one side.

Response to criticism and rejection

A psychologist may explore what happens when the person's self-esteem is challenged. For example, how do they respond when a partner disagrees with them, when they receive negative feedback at work, when someone else receives recognition, or when they experience rejection? Everyone can feel embarrassed, disappointed or defensive at times. What is clinically relevant is the pattern and intensity of the response.

For someone experiencing significant narcissistic difficulties, a relatively ordinary experience of criticism or rejection may trigger intense shame, anger, withdrawal, defensiveness or a strong need to restore their sense of importance or worth.

Entitlement and expectations

The Psychological assessment may also consider whether the person has an unusually strong expectation of receiving special treatment, recognition or compliance from others. For example, they may become particularly angry when someone does not prioritise their needs, expects them to follow the same rules as everyone else, or challenges their expectation of being treated differently. Importantly, the Psychologist will also consider how the person responds when their expectations are not met.

Patterns over time and across situations

Perhaps one of the most important aspects of assessment is consistency over time. NPD is not diagnosed because of a few arguments, one difficult relationship or a particularly stressful period. A Psychologist will consider whether the relevant characteristics represent a longstanding and pervasive pattern that occurs across different situations and relationships and causes significant impairment or distress.

For example, someone may behave very differently during a period of acute stress, grief or relationship breakdown than they ordinarily do. That temporary change in behaviour would need to be distinguished from a longstanding pattern of personality functioning.

Testing for Narcissism

Unfortunately, there is no blood test, brain scan or self-report questionnaire that can diagnose NPD. As Psychologists we may use structured clinical interviews and psychological assessment tools as part of an assessment, but questionnaires alone don't establish a diagnosis. This is particularly important when it comes to online “narcissist tests”. Sure they may identify some narcissistic traits, but they cannot tell you whether someone meets the clinical criteria for NPD.

A note about safety

If you are experiencing threats, intimidation, coercive control, physical violence, sexual violence or fear for your safety, the priority is safety rather than trying to determine whether someone has NPD.

You do not need a diagnosis or a label to seek support. Consider reaching out to a trusted person or an appropriate professional or domestic and family violence service. If you are in immediate danger, contact emergency services.

The bottom line

NPD isn't diagnosed from a TikTok checklist or because someone behaves badly in a relationship. It requires a comprehensive clinical assessment that considers longstanding patterns of self-esteem, relationships, empathy, entitlement and emotional functioning, as well as other possible explanations.

And perhaps most importantly, you definitely don't need to diagnose someone else in order to take your own experience seriously. If a relationship is leaving you confused, anxious, depleted or constantly questioning yourself, that experience is worth exploring in its own right.

At Motivating Marriages, we look beyond labels to understand the person, the relationship and the patterns that keep couples stuck.

By Carlie Kowald