Narcissistic Personality Disorder & Substance Abuse

By Team RehabAid

Last Updated March 22, 2024

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Narcissism is a popularized term that often describes people who care only about themselves and no one else. However, as a clinical condition, narcissistic personality disorder (NPD) is exemplified by a lack of empathy, impulsive behavior, an exaggerated sense of self-importance, and an intense need for attention. For people with this condition, these characteristics get so out of hand that their social and personal lives are greatly disrupted.

Narcissistic personality disorder (NPD) affects roughly 0.5% of the U.S. population (about 1.6 million people). According to the American Psychological Association (APA), over 60% of individuals diagnosed with NPD also have a co-occurring substance use disorder, most often with alcohol.

While people with NPD may appear to feel good about themselves on the surface, their inner world is often fraught with anger, shame, and feelings of unworthiness. Therefore, the sense of isolation and pressure to keep up the appearance of success can prompt individuals with NPD to turn to substance abuse to cope.

However, hope is not lost, as treatment is available for both narcissistic personality disorder and substance abuse. In this article, we outline what NPD is, how it overlaps with substance abuse, and what types of treatments are available.

What Is Narcissistic Personality Disorder (NPD)?

Narcissistic personality disorder (NPD) is a mental health condition that is characterized by a lack of empathy and an unrealistic view of oneself. As one of 10 other personality disorders in the Diagnostic and Statistical Manual (DSM-V), NPD is marked by non-emotion, severe or heightened arrogance, and a strong need for admiration.

Individuals with NPD tend to exhibit grandiose thoughts and fantasies about their importance, as well as traits such as impulsivity, attention-seeking, and unstable relationships. The irony of this condition is that although people with NPD portray themselves as confident, arrogant, and self-important, deep down they suffer from low self-esteem.

Many of these individuals also struggle with concurrent mental health disorders — substance abuse being one of the main ones. As a result, people with NPD often experience ongoing and pervasive problems with their jobs and interpersonal relationships.

Diagnosis

Like many personality disorders, a diagnosis of NPD is based on how much a person exhibits the baseline characteristics of the condition. Usually, an individual needs to meet 55% of the DSM-V criteria of NPD to qualify for a diagnosis.

However, as NPD exists on a spectrum, diagnosis can be complicated and confused with other concurrent conditions. Also, because people with NPD tend to think that nothing is wrong with them, they rarely seek treatment. Clinical diagnoses are thus usually provided when someone is exhibiting distress and marked impairment in their social and occupational life.

Co-Occurring Conditions With NPD

Narcissistic personality disorder (NPD) commonly occurs with other psychiatric conditions. Below are some of the main ones:

NPD and Major Depressive Disorder (MDD)

Major depressive disorder (MDD) is the most common co-occurring condition with NPD, with rates averaging around 45% to 50%. Some studies even indicate that the prevalence can be as high as 83% in some individuals with NPD. Symptoms of depression also present slightly differently in people with NPD, as it is likely to be accompanied by anger, paranoid thoughts, and self-protective behaviors.

While the exact cause is not known, psychiatric experts suggest that pathological narcissism often increases or leads to depression. This is because one of the key traits of NPD is to hide one’s flaws and maintain a “perfect” front with others. It is believed that this trait, combined with difficulty regulating emotions, can lead people with NPD to become depressed.

NPD and Bipolar Disorder

Another common co-occurring mental health condition is bipolar disorder, which is thought to affect between 5% and 11% of NPD patients. Bipolar disorder is characterized by intense swings between depression and mania and it can be difficult to diagnose, as symptoms of NPD and bipolar disorder overlap (e.g., impulsive behaviors and setting unattainable goals). Another difficulty with diagnosing NPD and bipolar disorder concurrently is that a person with narcissism may also present with symptoms of mania. However, a person with mania doesn’t necessarily have narcissism, and vice versa.

NPD and Trauma (PTSD)

Trauma is thought to be a contributing factor to the development of personality disorders like NPD. Some studies indicate that post-traumatic stress disorder (PTSD) is prevalent in about 25% of NPD cases. Like other mental health conditions, trauma can greatly impact a person’s emotional development.

Research suggests that traumatic experiences, like abuse or neglect, mixed with excessive appraisal from parents can lead to NPD. It can also arise from a combination of abuse and inadequate warmth in the household. These two conditions can also be “bi-directional,” in that people with NPD are likely to have PTSD and people with PTSD are also more likely to develop NPD.

NPD and Other Personality Disorders

NPD also commonly co-occurs with other personality disorders such as antisocial, histrionic, borderline, schizotypal, and passive-aggressive personality disorders. Borderline personality disorder (BPD) is one of the most frequently co-occurring, as 16% to 39% of patients meet the diagnostic criteria for NPD. Unsurprisingly, the complexity of having NPD and BPD exacerbates characteristics of both conditions, such as impulsivity and manipulation.

Signs of Narcissistic Personality Disorder

Signs of narcissistic personality disorder can vary between each person, but below are the main signs to look out for:

• An exaggerated sense of self-importance.
• Manipulative behavior.
• A sense of entitlement, and requiring constant, excessive admiration.
• Constant comparison with others.
• Expecting to be recognized as superior, without any achievements that warrant it.
• A deep need to be right.
• Impulsive decision-making.
• Exaggerating achievements and talents.
• Being preoccupied with fantasies about success, power, or the perfect mate.
• Believing they are superior and can only associate with equally special people.
• Poor self-esteem.
• Monopolizing conversations and belittling or looking down on people they perceive as inferior.
• Expecting special favors and unquestioning compliance with their expectations.
• Taking advantage of others to get what they want.
• An unwillingness to recognize the needs and feelings of others.
• Being envious of others and believing others envy them.
• Behaving arrogantly, coming across as conceited, boastful, and pretentious.
• Insisting on having the best of everything.

Underlying Risk Factors

While there is no exact cause of narcissistic personality disorder, there are several key risk factors. These include:

Neurobiology

While fewer studies have been done on NPD than other personality disorders, scientists believe there may be a connection with the brain areas responsible for behavior, thinking, and empathy. For example, neuroimaging studies have shown reduced grey matter in particular areas of the insular cortex, an area in the brain that is involved in generating and feeling empathy.

Genetics

Like other mental health conditions, scientists also believe there is a genetic link, as NPD can run in families. They also suggest that inherited traits like aggression may increase the risk of NPD, especially when combined with environmental factors.

Environmental Factors

Numerous environmental factors are suspected to be at play when it comes to NPD. These include parental behaviors such as excessive adoration (or even excessive criticism), childhood abuse, neglect, or violent and unstable families. These factors can contribute to NPD and other concurrent disorders, like substance abuse.

How Do NPD and Substance Abuse Overlap?

Substance abuse rates among those with NPD are very high, and the two conditions also overlap in several ways:

• NPD and substance abuse disorder are marked by impulsive behaviors.
• People with NPD and substance abuse disorder tend to engage in self-medication.
• People with NPD and substance abuse disorder often avoid their emotions or are in denial about them.
• People with NPD and substance abuse disorder can exhibit symptoms of depression, anxiety, and mania.
• NPD and substance abuse disorder involve a pattern of instability in terms of relationships, finances, and employment.
• NPD and substance abuse disorder are evidenced by behaviors that are often manipulative, domineering, or deceitful.
• People with NPD and substance abuse disorder can sometimes be co-dependent on others, while displaying black and white thinking that is difficult to change.

Why Do People With NPD Engage in Substance Abuse?

Individuals with narcissistic personality disorder often abuse substances for several reasons, as outlined below.

To Self-Medicate

One of the most common reasons people with mental health conditions turn to substances is to self-medicate. For people with NPD, their inner world can be isolating and lonely, and the pressure they put on themselves to display a particular appearance can lead to depression. Therefore, the irony is that, although individuals with NPD appear to feel good about themselves, in reality they often suffer from feelings of worthlessness, shame, helplessness, and anger.

It is therefore no surprise to learn that people with NPD often turn to substances to feel comfort, relaxation, and a sense of belonging. However, the problem with using drugs or alcohol to achieve relief is that it not only leads to addiction, but it can also exacerbate NPD symptoms, particularly when the substances wear off.

As a Consequence of Substance Use

A large proportion of individuals with NPD also meet the criteria for substance use disorder, which is why scientists question whether drug addiction can cause narcissism. To complicate matters more, people who have an active substance addiction can also display symptoms of NPD. Therefore, there are cases where symptoms of NPD are present in the early stages of addiction, and substances only make things worse. In turn, these symptoms can cause individuals with NPD to relapse or take more substances to cope.

How Does Substance Abuse Affect Narcissistic Personality Disorder?

Another factor when it comes to NPD and substance abuse is how they influence each other. Below are some of the common substances that are abused by individuals with NPD.

Alcohol & NPD

Rates for alcohol use among people with NPD are roughly 22%, which is nearly 4 times higher than the general population. Alcohol is also the most abused substance by people with NPD, and while the reasons are not entirely clear, some research suggests that it’s because of the widespread availability of alcohol and its social acceptability. While drinking on occasion isn’t necessarily harmful, using it long term can lead to health problems and a worsening of NPD symptoms, such as depression.

Stimulants & NPD

Stimulants are another widely abused drug by people with a narcissistic personality disorder. Individuals with NPD can sometimes be dependent on the increased energy and confidence that accompanies stimulant use. People with NPD also feel the need to keep up successful appearances and stimulants are seen as a way to boost and enhance that image. Some of the most abused stimulants by people with NPD include Adderall, Ritalin, cocaine, methamphetamine, and ecstasy.

Cannabis & NPD

Cannabis is a widely abused drug by people with mental health conditions, especially because it is more socially acceptable (like alcohol). However, what complicates cannabis is that it can work as both a depressant and a stimulant, depending on the individual and how it is taken. While cannabis can be effective at helping someone relax, high levels of the drug are also linked with negative NPD symptoms such as paranoia, anxiety, and irritability.

Benzodiazepines & NPD

Prescription drugs such as benzodiazepines (benzos) are also abused by individuals with NPD. The problem with benzos is that they have been known to increase impulsivity, violence, and aggression in people with NPD. While benzos can provide relief for tension and anxiety, they are best avoided.

NPD & Substance Abuse Stats

• In the U.S., narcissistic personality disorder affects roughly 1 in 200 people.
• There is a big gender split when it comes to NPD: some studies indicate that 75% of people with NPD are men.
• According to the National Institute of Mental Health (NIMH), a large proportion of people (84.5%) with personality disorders in the last year also had one or more mental health conditions.
• It is estimated that roughly 15% of people with a narcissistic personality disorder also have depression, while 13.5% of those have anxiety.
• 17% of people with pathological narcissism are also estimated to have either bipolar I or bipolar II disorder.
• More than 40% of individuals with NPD also have a substance use disorder.
• 14% of people with narcissistic personality disorder are estimated to have an alcohol use disorder, while 24% abuse other substances.

Narcissistic Personality Disorder & Substance Abuse Treatment Options

In general, personality disorders can be trickier to treat than other mental health disorders. In the case of narcissistic personality disorder, this is largely because these individuals often feel there is nothing wrong with them. They can also be difficult to deal with and make unrealistic demands on their therapists, especially if they are not fully aware of their condition.

However, despite the complexity of conditions like NPD and substance abuse, treatment is available. These conditions are best managed using multiple levels of care that start with detox and continue through to inpatient/residential, outpatient, and aftercare programs.

If you need to seek help, many of these programs can be found in rehab facilities or drug treatment centers across the country.

Dual Diagnosis

Centers that offer dual diagnosis treatment are recommended, as they are set up to diagnose and treat concurrent mental health conditions and substance abuse. This kind of treatment is especially useful for people who have underlying issues such as NPD, bipolar disorder, anxiety, and depression. Dual diagnosis programs allow clinicians to safely address these conditions while an individual withdraws from alcohol or drugs. Dual diagnosis can be found in both inpatient and outpatient clinics.

Key Therapies

Other key treatments to be aware of when it comes to anxiety and substance abuse are:

Cognitive-Behavioral Therapy (CBT)

One of the best therapies for NPD and substance abuse is cognitive-behavioral therapy (CBT). CBT helps individuals change negative cycles of thought and behavior into more positive ones. When it comes to NPD, especially, CBT can help identify where a person’s impulsive behavior and grandiose sense of self originates. Clients receiving CBT for addiction often learn how to recognize “automatic thoughts” and dysfunctional thinking patterns, how to understand the behavior and motivation of others, and how to develop a greater sense of self-understanding and confidence. CBT also learn how to find solutions to triggers that might encourage drug use.

Dialectical-Behavior Therapy (DBT)

Dialectical-behavior therapy (DBT) is often the gold-standard treatment for borderline personality disorder (BPD), but it is also considered effective for NPD. DBT is a type of cognitive-behavioral therapy that focuses on mindfulness, how to live in the moment, cope with stress, and improve relationships. DBT also helps clients better regulate their moods, impulsiveness, and how to develop healthy coping skills. This kind of therapy is useful for people who have co-occurring conditions, especially those who have NPD, depression, or bipolar symptoms. DBT is also effective for PTSD and for people who exhibit self-destructive behaviors.

Trauma Therapies (EMDR)

Since a history of trauma and abuse can cause or exacerbate NPD, trauma treatments such as eye movement desensitization and reprocessing (EMDR) are also effective. Consisting of 8 phases, EMDR is led by a therapist who guides an individual through a series of rapid eye movements to help redirect negative or traumatic memories. This redirection helps the person form new connections or associations, so that the memory is less emotionally distressing over time. This therapy is therefore useful for individuals with mood disorders, as it helps them overcome the emotional suffering associated with traumatic events.

Psychodynamic Treatment

Psychodynamic therapy consists of the psychological interpretation of mental and emotional processes and is another suggested treatment for NPD. This type of therapy is rooted in traditional psychoanalysis and can be seen as a simpler and less complicated alternative. The aim of this treatment is to address the foundation and formation of psychological processes, such as thoughts, emotions, beliefs, and early life experiences — all of which are crucial in treating someone with narcissistic personality disorder. Psychodynamic treatment has been shown to be effective at helping to reduce symptoms and improve the lives of people with NPD.

Medications

While there are no specific medications for narcissistic personality disorder and substance abuse, the following are sometimes used to ease symptoms of other co-occurring conditions.

Anti-Depressants

Anti-depressants are often used to help treat co-occurring depression in individuals with NPD. The most commonly prescribed are selective serotonin reuptake inhibitors (SSRIs), which tend to have fewer side effects than other antidepressants. Common SSRI medications include Prozac, Zoloft, and Paxil.

Antipsychotics

Another useful drug for treating NPD and addiction is antipsychotics. These drugs can be useful for reducing anxiety, depression, and impulsivity, which are symptoms that are also present with substance abuse. Common antipsychotics include Abilify and Risperdal.

Mood Stabilizers/Anticonvulsants

As mood disorders commonly co-occur with NPD, mood stabilizer drugs are also sometimes prescribed. These drugs are useful for treating addiction, impulsive behavior, and rapid mood changes. Common mood stabilizers include lithium, Lamictal, and Tegretol.

Alternative or Holistic Therapies

Holistic therapies are also effective at treating addiction and mental health disorders. The purpose of holistic therapies is to treat the whole person and not just the symptoms. These can be incredibly beneficial for providing calmness, spiritual support, emotional expression, improving physical health, and teaching valuable skills. Some of the popular holistic therapies include:

• Relaxation techniques
• Nutritional therapy
• Animal-assisted therapy (e.g., emotional support dogs)
• Massage
• Adventure therapy (e.g., hiking or rock climbing)
• Mindfulness and meditation
• Art therapy and music therapy
• Yoga and tai-Chi
• Equine-assisted (horse) therapy

Long-Term Recovery

Alongside these treatments, there are other ways to enhance your recovery by making personal lifestyle adjustments like the ones below:

Exercise

This can stimulate endorphins, which can help with anxiety, depression, and low mood. Examples include low- and high-intensity exercises such as walking, running, swimming, cycling, or yoga.

Meditation

This can help calm anxious thoughts and reduce impulsive behavior, which is useful when recovering from NPD and addiction.

Eating Well

The right diet can help repair damage incurred following sustained drug use and lead to improved immunity, cognitive function, and energy.

Avoiding Triggers

Learning to avoid triggers like certain people, situations, or circumstances can help prevent NPD symptoms and a desire to take drugs.

New Hobbies

While cravings can be difficult to manage, hobbies such as sports, art, music, or crafts can be useful distractions.

Resources

If you or a loved one are struggling with narcissistic personality disorder and substance abuse or addiction, you are not alone. Treatment and support are readily available. Contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment.

You can also find a list of treatment centers near you on our website to help get you on the path to recovery.

Key Sources

Caligor, E., Levy, K., and Yeomans, F. (2015). Narcissistic Personality Disorder: Diagnostic and Clinical Challenges. American Journal of Psychiatry. 172(5), 415-422.

Kacel, K., Ennis, N., and Pereira, D. (2017). Narcissistic Personality Disorder in Clinical Health Psychology Practice: Case Studies of Comorbid Psychological Distress and Life-Limiting Illness. Behav Med. 43(3), 156–164. https://10.1080/08964289.2017.1301875

Lesser, B. (2021). Narcissism and Addiction: The Determining Factors. Dual Diagnosis.org. https://dualdiagnosis.org/narcissism-addiction.

Mayo Clinic. (n.d.). Narcissistic personality disorder. Mayo Clinic.org. https://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/symptoms-causes/syc-20366662.

National Institute of Mental Health. (n.d.). Personality Disorders. NIHM. https://www.nimh.nih.gov/health/statistics/personality-disorders.

Ronnington, E., and Weinberg, I. (2013). Narcissistic Personality Disorder: Progress in Recognition and Treatment. Focus. 11(2), 167-177.

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At RehabAid.com, we are dedicated to helping people recover from problematic substance use and associated mental health disorders. If you or a loved one are struggling with addiction to drugs or alcohol, you are not alone. Information on treatment and support options is readily available through the National Helpline of the Substance Abuse and Mental Health Services Administration (SAMHSA) at 1-800-662-4357. To further assist you along the path to recovery, the treatment center locator on our website allows you to easily find rehabilitation programs and services in your local area.

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