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You may have someone in your life that needs constant praise, is intensely jealous of other people, and gets furious with the slightest criticism. You may have a co-worker that brazenly steals your ideas, constantly lies, and is exceptionally manipulative.
These traits are possible signs of a narcissistic personality disorder. This condition is extremely difficult to deal with, especially if the person is close to you or you interact with them often. In extreme cases, a person with these traits may be called a malignant narcissist.
What is narcissistic personality disorder?
Narcissistic personality disorder (NPD) is defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as having at least five of nine traits, which are divided into four areas (Mitra, 2021):
- The first area embodies ways of responding emotionally. The symptoms include a constant need for praise and attention or having a sense of entitlement.
- The second area is all about ways of thinking about yourself or others. The symptoms here are a grandiose sense of self-worth, a belief that you’re extraordinary, or having constant fantasies about power or success.
- The third area is impulse or behavior control. The symptoms are jealousy of others or intense rage.
- The fourth area is interpersonal—how you relate to others. The symptoms are an attitude of arrogance or self-importance, an expectation of special treatment, lack of empathy, inability to see the needs and feelings of others, or exploiting people for your own needs.
Many of us have one or two of these narcissistic personality traits on occasion. When at least five of these nine symptoms happen consistently and interfere with a person’s interpersonal relationships and daily life, that person may be diagnosed with NPD (Mitra, 2021).
Classic Greek mythology introduced the concept of narcissism or excessive self-love thousands of years ago, with the story of Narcissus, who was so obsessed with himself that he couldn’t stop staring at his own reflection. Researchers and mental health professionals have been fascinated by this complex condition ever since (Levy, 2011).
Though it’s not an official diagnosis, mental health experts say malignant narcissism is the most severe form of narcissistic personality disorder.
What is malignant narcissism?
When you hear or read the word malignant, you may think, as many other people do, that it’s connected to cancer and other harmful things. The Merriam-Webster dictionary defines malignant as “tending to produce death or deterioration or evil in nature, influence, or effect” (Merriam-Webster, 2021).
Malignant narcissistic behavior is hostile, spiteful, malicious, and dangerous.
In 1964, Erich Fromm, a social psychologist, coined the term “malignant narcissist.” Twenty-four years later, Otto Kernberg expanded on the different aspects of malignant narcissism. He said a malignant narcissist has four characteristics (Goldner-Vukov, 2010):
- A narcissistic personality disorder with at least five narcissistic traits as defined by the American Psychiatric Association and that occur consistently.
- Antisocial behavior where they show contempt for others—they may commit assault, burglary, or even murder.
- A type of sadism, where they seek to destroy or dehumanize people they feel have insulted or crossed them. Rage and revenge fuel them.
- Deep paranoia about others with a deep sense of mistrust and lack of empathy toward others.
In 2015, Eva Caligor, a psychiatrist, described two other types of narcissistic personality disorder behavior.
One is vulnerable narcissism, characterized by hypersensitivity, defensiveness, anxiety, and a need for constant emotional support. The second is grandiose narcissism, characterized by grandiosity and extreme arrogance. They have an intense need for power, praise, and positive attention (Caligor, 2015).
Borderline personality disorder (BPD): testing, types, and traits
Each of these categories has several variations at either extreme. At the very end of the continuum of narcissistic personality disorder is malignant narcissism. This most severe type encompasses both of Caligor’s categories.
Malignant narcissists don’t just want to have the spotlight shining on them and for everyone to think they are a smashing success. They have a far darker side, as we’ll discuss below.
What are the traits of malignant narcissism?
Malignant narcissists have similar character traits to a person with a narcissistic personality disorder. They include the same expectations, emotions, and behavior characteristics of NPD but are more extreme (Goldner-Vukov, 2010).
- Expectations: People with malignant narcissism expect to be treated as unique and deserving of the best of everything.
- Emotions: People with malignant narcissism lash out at others for actual or perceived insults. They are preoccupied with fantasies of themselves with unlimited power, success, brilliance, and beauty. They have an overinflated sense of self and their abilities and an inability to regulate their emotions.
- Behavior: People with malignant narcissism behave with narcissistic abuse. They act with aggressive behavior in situations that do not require it. They lack empathy towards others and exploit and take advantage whenever they can. They dominate or monopolize conversations, mistreating people they feel are beneath them. They do not handle any sort of criticism. They have zero remorse, apologize only when it benefits them, and blame others for their behaviors. Lastly, they may manipulate others so thoroughly that the other people question their own sanity. This behavior is called gaslighting.
Danger signs of malignant narcissism
People with malignant narcissism have pathological narcissism, as defined by Otto Kernberg. Their behaviors are self-focused, antisocial, and paranoid, with a sadistic streak running through all of their actions. They may be highly manipulative, seeking to win no matter what the costs are. They do not care who they hurt, and they may even enjoy inflicting emotional or physical pain on others. They always protect themselves first (Goldner-Vukov, 2010).
Some people say that malignant narcissists are sociopaths or psychopaths because their behaviors create significant, even life-threatening, harm to others.
There is almost no difference between a psychopath and a malignant narcissist from a clinical perspective. Experts who research serial killers, sexual murderers, and mass murderers indicate that these people have a complete disregard for others, lack empathy, and blame others for their behaviors, similar to malignant narcissists (Black, 2015).
Munchausen syndrome: signs, causes, treatment
Because of these potential dangers, it’s important to watch out for signs of malignant narcissism so you can keep yourself safe.
Diagnosing malignant narcissism
While narcissistic personality disorder is an official diagnosis in the DSM-5, malignant narcissism is not. Despite the lack of an official diagnosis, many mental health professionals agree on how malignant narcissistic symptoms present. There is also some consensus to include malignant narcissism as part of the narcissistic personality disorder diagnosis (Campbell, 2011).
Mental health professionals use the diagnostic criteria set forth by the American Psychiatric Association in the DSM-5 for narcissistic personality disorder, paranoia, and antisocial personality disorder to diagnose malignant narcissism (Mitra, 2021).
A narcissistic personality disorder is when a person has five of the following nine narcissistic personality traits (Mitra, 2021):
- A grandiose sense of self-importance and self-worth—where a person exaggerates or invents their talents or achievements
- Being preoccupied with constant fantasies of power, brilliance, love, beauty, or unlimited success
- Believing they are “uniquely special” and can only be with certain people who appreciate them
- Requiring excessive admiration
- Having a sense of entitlement or the unreasonable expectations of receiving special treatment or immediate responses to their needs
- Exploiting others and taking advantage of others to achieve their own goals
- Lack of empathy and unwillingness to recognize or see the needs or feelings of others
- Feeling constant jealousy of others or believing that others are constantly jealous of them
- Behaving or showing arrogance or haughtiness
An antisocial personality disorder requires a person to be at least age 18 or older and to have at least three of the following impulsive behaviors that they have done starting from age 15 (Fisher, 2019):
- They show utter disregard for the physical or emotional safety of themselves or others.
- They have a pattern of irresponsibility and behave impulsively and aggressively.
- They blatantly disregard social or cultural norms or disobey laws.
- They lie or manipulate others for their own amusement or profit.
- They show a lack of remorse for their actions.
If a person has both narcissistic personality disorder and antisocial personality disorder with paranoid features, and seems to enjoy causing harm to others, they may be diagnosed with malignant narcissism.
How do you treat malignant narcissism?
If you have a loved one with the features of narcissistic personality disorder or malignant narcissism, you may find their behavior very distressing. You may want to seek treatment for them, both for their benefit and your own.
There is limited research on the efficacy of treatments for both NPD and malignant narcissism. Psychotherapy works best when the person needing treatment is seeking help and is committed to doing the work. Narcissists and malignant narcissists do not usually seek diagnosis or treatment, as they do not feel anything is wrong with them. If forced to go for help, many malignant narcissists think they are “above treatment” and require skillful, intelligent, and delicate handling (Weinberg, 2020).
Psychotherapy is recommended to help people with malignant narcissism to understand how their behaviors affect and harm their interpersonal relationships. People diagnosed with narcissistic personality disorder and malignant narcissism may need long-term psychotherapy to treat their behavior (Campbell, 2011).
Psychotherapy: everything you need to know
The types of psychotherapy recommended for malignant narcissism are (Campbell, 2011):
- Psychodynamic therapy
- Dialectical behavior therapy
- Family therapy
- Couples therapy
Schema therapy also shows some promise in treating malignant narcissism (Diekman, 2015).
More research is needed to see the long-term effects of psychotherapy on narcissistic behavior, including malignant narcissism.
There are no medications to treat either narcissistic personality disorder or malignant narcissism. However, many people with either NPD or malignant narcissism have co-occurring psychiatric disorders, including borderline personality disorder (BPD), antisocial personality disorder (APD), and substance use disorders, and medications may be prescribed to treat these conditions (Ronningstam, 2016).
If medications are prescribed, they are used to treat some of the symptoms of NPD like irritability, anger, or paranoia or to treat the underlying mental health condition. These medicines include antidepressants, antipsychotics, or mood stabilizers (Ronningstam, 2016).
Can you live or work with someone who has malignant narcissism?
Narcissistic behaviors can be very challenging to live or work with. It may be best to keep far away from people with malignant narcissism, but if your loved one or coworker has these character traits, you may not be able to do so (Weinberg, 2020).
Here are a few tips to help you manage regularly interacting with someone with this disorder:
- Limit your interactions with them as much as possible. This means setting both physical and emotional boundaries for yourself.
- Accept that they cannot change their behavior without acknowledging that they have a problem. People with narcissism do not think they have a problem with their behavior.
- If you need to challenge them, do it privately and stick to the facts. Malignant narcissists have an inflated ego and feel insulted, even by constructive criticism. If other people are present when you confront them, they may retaliate in brutal ways to avenge their honor.
- Keep your friends, family, or other support people close. It is difficult to let go of the negativity and anger directed towards you from the person with malignant narcissism. By keeping positive people around you, it can shield you from their distressing behavior.
If you think your loved one has some of the character traits of malignant narcissism, seek help from a mental health professional. They can help you learn to set effective boundaries, coping skills, and self-care tools. You may also want to attend a support group to learn from others in your situation. Although malignant narcissism has no cure, you can help yourself by knowing what to expect and how to deal with their behaviors safely.
- Black D. W. (2015). The natural history of antisocial personality disorder. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 60(7), 309–314. doi: 10.1177/070674371506000703. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26175389/
- Caligor, E., Levy, K. N., & Yeomans, F. E. (2015). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5), 415-422. doi: 10.1176/appi.ajp.2014.14060723. Retrieved from https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.14060723
- Campbell, W. K., & Miller, J. D. (2011). Conclusion: narcissism and narcissistic personality disorder: Six suggestions for unifying the field. The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments, 485-488. doi: 10.1002/9781118093108.oth1. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1002/9781118093108.oth1
- Dieckmann E, Behary W. (2015). Schematherapie: Ein Ansatz zur Behandlung narzisstischer Persönlichkeitsstörungen [Schema therapy: an approach for treating narcissistic personality disorder]. Fortschr Neurol Psychiatr. 83(8):463-77; quiz 478. Translated from German. doi: 10.1055/s-0035-1553484. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26327479/
- Fisher, K. A., & Hany, M. (2019). Antisocial personality disorder. StatPearls [Internet]. Retrieved from: https://www.statpearls.com/ArticleLibrary/viewarticle/17712
- Goldner-Vukov M, Moore LJ. (2010). Malignant narcissism: from fairy tales to harsh reality. Psychiatr Danub. 22(3):392-405. Retrieved from https://pubmed.ncbi.nlm.nih.gov/20856182/
- Levy, K. N., Ellison, W. D., & Reynoso, J. S. (2011). A historical review of narcissism and narcissistic personality. The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments, 3-13. doi: 10.1002/9781118093108.ch1. Retrieved from https://onlinelibrary.wiley.com/doi/10.1002/9781118093108.ch1
- Merriam-Webster. (2021). Dictionary. Define: malignant. Retrieved from https://www.merriam-webster.com/
- Mitra, P., & Fluyau, D. (2020). Narcissistic personality disorder. StatPearls [Internet]. Retrieved from https://www.statpearls.com/ArticleLibrary/viewarticle/27055
- Ronningstam, E. (2016). New insights into narcissistic personality disorder. Psychiatric Times, 33(2): 11. Retrieved from https://www.psychiatrictimes.com/view/new-insights-narcissistic-personality-disorder
- Weinberg, I., & Ronningstam, E. (2020). Dos and don’ts in treatments of patients with narcissistic personality disorder. Journal of Personality Disorders, 34 (Supplement), 122-142. doi: 10.1521/pedi.2020.34.supp.122. Retrieved from https://guilfordjournals.com/doi/abs/10.1521/pedi.2020.34.supp.122
Dr. Steve Silvestro is a board-certified pediatrician and Senior Manager, Medical Content & Education at Ro.