Unpacking Malignant Narcissism

Malignant narcissism can present in many ways — there’s no set list of traits. It’s also very hard, especially for someone who isn’t a mental health professional, to differentiate between malignant narcissism and severe NPD.

This is partly why it’s best to avoid using this term (or related ones, such as narcissist) to refer to someone, especially if you aren’t a mental health professional with knowledge of the person’s background.

And again, there’s no expert consensus on the criteria for malignant narcissism. But many mental health experts support its existence as part of the narcissism spectrum. There’s also some general agreement on possible presentation of symptoms.

But this type of narcissism might appear with any combination of symptoms from the following categories.

NPD

Like other personality disorders, NPD occurs on a spectrum and involves a range of symptoms. The DSM-5 lists nine traits that help identify NPD, but only five are needed for diagnosis.

Common symptoms of NPD include:

• grandiose fantasies and behavior, such as a preoccupation with thoughts of personal success, power, and attractiveness or sex appeal
• little or no empathy for other people’s emotions or feelings
• a significant need for attention, admiration, and recognition
• an inflated sense of self-importance, such as a tendency to exaggerate personal talent or achievements
• a belief in personal specialness and superiority
• a sense of entitlement
• a tendency to take advantage of others or exploit people for personal gain
• arrogant or conceited behavior and attitudes
• a tendency to envy others and believe others envy them

People with NPD often have trouble dealing with change. They may feel depressed or humiliated when they feel slighted, have a hard time with insecurity and vulnerability, and react angrily when others don’t seem to regard them with the admiration they need and feel they deserve.

This condition also tends to involve difficulty managing emotions and behavioral responses to stress.

APD

The primary features of this condition are consistent disregard for other people’s feelings. This can include manipulation and deceit as well as physical or emotional abuse. Another key component is a lack of remorse for wrongdoing.

Violent or aggressive behavior can be a sign of this condition, but some people living with APD never behave violently.

People living with APD typically show symptoms of conduct disorder in childhood. This may include violence toward other people and animals, vandalism, or theft. They generally don’t consider or care about the consequences of their actions.

Only adults are diagnosed with APD. A diagnosis requires at least three of the following symptoms:

• disdain for authority and social norms, shown by continued illegal or lawbreaking behavior
• a pattern of deceit, including exploitation and manipulation of other people
• reckless, impulsive, or risky behavior that shows disregard for personal safety or the safety of other people
• little or no remorse for harmful or illegal actions
• a generally hostile, irritable, aggressive, restless, or agitated mood
• a pattern of irresponsible, arrogant, or disrespectful behavior
• difficulty planning ahead

Aggression

Aggression describes a type of behavior, not a mental health condition. People can’t be diagnosed with aggression, but a mental health professional or other expert may note acts of aggression as part of a diagnostic profile.

Aggressive behavior can occur as a response to anger or other emotion and generally involves an intent to harm or destroy. There are three main types of aggression:

• Hostile aggression. This is behavior specifically aimed at injuring or destroying someone or something.
• Instrumental aggression. This is an aggressive act that relates to a specific goal, such as smashing a car window to steal a wallet.
• Affective aggression. This refers to behavior usually directed at a person or object that triggered an emotion. It may also be redirected if it isn’t possible to target the actual source. Punching a wall instead of punching another person is an example of affective aggression, particularly when the action involves a desire to cause damage.

Sadism

Sadism is taking pleasure in humiliating someone or causing them pain.

The DSM-5 lists sexual sadism disorder as a condition that involves sexual arousal linked to the idea of causing a non-consenting person unwanted pain. But sadism itself is not a mental health diagnosis, nor is it always sexual.

People with sadistic tendencies may:

• enjoy hurting others
• enjoy watching others experience pain
• derive sexual excitement from seeing others in pain
• spend a lot of time fantasizing about hurting other people, even if they don’t actually do so
• want to hurt others when irritated or angry
• enjoy humiliating others, especially in public situations
• tend toward aggressive actions or behavior
• behave in controlling or domineering ways

Some experts suggest that sadistic behavior helps set NPD and malignant narcissism apart. Narcissism often involves self-centered pursuit of desires and goals, but people with NPD might still show some remorse or regret for hurting others in the process.

Many people use the term sociopath in casual conversation. You might hear it used to describe people who don’t seem to care about other people or who take advantage of and manipulate their loved ones.

Sociopathy usually refers to the characteristics and behavior commonly seen with APD. But similarly to malignant narcissism, sociopathy is only used as an informal term, not a specific diagnosis.

Malignant narcissism isn’t the same as sociopathy, since APD traits are only part of this narcissism subtype.

In general, therapy can help anyone who seeks treatment with the intent of putting in the effort to improve their feelings, behaviors, or emotional reactions.

It’s certainly possible people living with malignant narcissism, or any other type of narcissism, can go to therapy and work to change behaviors that have a negative effect on their quality of life or on their family members, partners, and friends.

Seeking help

People living with traits of any type of narcissism may not seek help on their own. They often don’t realize there’s anything wrong with their actions and behavior.

But they might have other symptoms that prompt them into treatment, including:

• depression
• irritability
• anger management issues

In other cases, they might be motivated to enter therapy because of a court order, ultimatum from a romantic partner or family member, or another reason.

However, for treatment to be effective, they must ultimately want treatment for themselves.

Treatment options

If you think someone close to you might be dealing with a personality disorder, such as NPD or APD, it’s important to remember that it’s absolutely possible to change. Therapy can help, as long as they’re willing to work to do the work involved.

Therapy is often difficult, but it usually pays off with major benefits, including:

• stronger interpersonal relationships
• improved emotional regulation
• better ability to work toward goals

Certain types of therapy may be more helpful at treating narcissism.

A 2010 review of studies looking at malignant narcissism notes that treatment can prove challenging, particularly when aggressive or sadistic tendencies emerge in the therapeutic relationship.

But taking personal responsibility for treatment can lead to better outcomes. Recommended types of therapy include modified dialectical behavior therapy (DBT) and couples and family counseling, where applicable.

Medications such as antipsychotics and selective serotonin reuptake inhibitors (SSRIs) may also improve some symptoms, including anger, irritability, and psychosis.

A more recent journal article from 2015 suggests that schema therapy may also be helpful for NPD and related issues. Other research supports this finding.

Other approaches that could improve treatment outcomes include transference-focused therapy and mentalization-based therapy.

However, clinical data on this topic is lacking. More research is needed on therapy for narcissism.

Narcissism and related issues usually involve difficulty relating to and understanding the feelings of other people. You might notice signs, such as self-serving behavior, manipulative words and actions, or a pattern of unhealthy or failed relationships.

Maintaining family or interpersonal relationships may be even more challenging for a person with malignant narcissism. It’s not uncommon for relationships to involve controlling behavior, gaslighting, and emotional abuse.

If you’re close to someone living with malignant narcissism, it’s important to take care of yourself and watch for signs of abuse.

There are many different types of abusive behavior, and some may not seem as clearly abusive as others. Common signs can include:

• pointing out “flaws” and seeming to enjoy making you feel discouraged or upset, or saying they’re doing it for your own good
• lying or manipulating you to achieve their own goals, and justifying their behavior and showing no guilt or regret if you call them out on it
• putting you down, humiliating you, or threatening you, in public or private
• appearing to enjoy inflicting physical harm
• showing no interest in your needs or feelings
• behaving in risky or dangerous ways, without caring if you or other people get hurt in the process (e.g., driving dangerously and laughing when you express fear)
• saying or doing unkind or cruel things and appearing to enjoy your distress
• behaving aggressively toward you and other people or things

Someone’s mental health isn’t an excuse for abusive behavior. It’s also important to remember that abusive behavior isn’t always the result of a mental health condition.

If you believe your relationship has become unhealthy, talking to a therapist can help you decide what to do. You can also seek support from the National Domestic Violence Hotline at their website or by calling 800-799-7233.