What the DSM-5-TR says (2022)

The DSM-5-TR defines NPD as an enduring pattern — present from early adulthood, across a range of contexts — of grandiosity (in fantasy or behaviour), need for admiration and lack of empathy. It is established by at least five of the following nine criteria, given here in condensed form:

1. a grandiose sense of one’s own importance (expecting to be recognised as superior);
2. preoccupation with fantasies of success, power, beauty or ideal love;
3. the belief that one is special and unique, and can only be understood by high-status people or institutions;
4. an excessive need for admiration;
5. a sense of entitlement, that is, unreasonable expectations of favourable treatment;
6. interpersonal exploitation;
7. a lack of empathy (cognitive empathy is sometimes preserved, affective empathy impaired);
8. envy of others, or the belief that others envy us;
9. haughty, arrogant attitudes or behaviours.

Prevalence. Estimates in the general population range from roughly 0.5% to 6% depending on the study and the methodology (NESARC, Medscape, among others). Rates are higher in clinical settings, and the literature also reports sex differences depending on which dimensions of narcissism are measured (Stinson et al., 2008; Caligor et al., 2015; Medscape, 2025).

Differential diagnosis with mood disorders. Grandiosity may evoke a (hypo)manic episode, but that episode is episodic — with, for instance, a reduced need for sleep — whereas NPD is more chronic and more rigid (Mitra et al., 2024).

“Narcissistic pervert”: a concept that can be useful, but not a diagnosis

Narcissistic perversion was introduced by Paul-Claude Racamier between 1986 and 1992, in lectures and chapters later collected in Les perversions narcissiques (Payot). It describes processes of psychological hold that attack the other’s thinking and turn the bond into an instrument. It is a psychoanalytic conceptual framework: it is not a DSM category (Racamier, 1992/2012; Denis, 2014).

Where does the confusion come from? The word “narcissistic” has spread through public discourse, with the risk of labelling harsh behaviours (gaslighting, control) as those of a “narcissistic pervert” without any clinical assessment whatsoever.

A useful reminder: only a qualified professional makes a diagnosis of NPD, on the basis of an interview, a developmental history and the DSM criteria — not from a list found online.

A systemic reading: from “why” to “how it keeps going”

Systemic thinking favours circularity — A influences B, who influences A, and so on — and the feedback loops that maintain a relational balance (homeostasis). In couples where one partner presents with NPD, two loops come up again and again.

A few relational avenues for intervention

• Map the loop together — who does what, just before what? — and identify the triggers.
• Regulate symmetry: introduce pauses, name the first sign of escalation, agree on a de-escalation ritual.
• Work on empathy, from its cognitive to its affective dimension, and allow positions of power to alternate so as to reduce complementary rigidity.

Violence and NPD: increased risk is not fate

The data distinguish narcissism as a “trait”, measured in the general population, from NPD as a constituted disorder. Recent meta-analyses show a positive but weak-to-moderate association between narcissism and aggression or violence, with a stronger link for vulnerable narcissism in intimate partner violence.

In other words: risk is not destiny. Context, co-occurring features — antisocial traits, for example — and the quality of relational regulation strongly shape the trajectories (Du et al., 2022; Oliver et al., 2023/2024).

Why this distinction genuinely helps

Separating the diagnosis from the concept is not a theoretical nicety. It changes, in practice, what can be done with a situation:

• it avoids sweeping labels (“he or she is a pervert”) and opens up a shared language for working on processes — how does this relationship spiral out of control?;
• it brings relief to some couples and families: understanding the mechanisms (admiration/disappointment, vulnerability/control) makes it possible to change the loops rather than assign an essence to one of the partners;
• it reduces stigma for people living with NPD. Understanding is not excusing, but it increases the chances that interventions will work (Weinberg & Ronningstam, 2022; McLean Hospital, n.d.).

In closing

Talking about a diagnosis only makes sense if it sheds light on interactions and offers concrete levers for change. Systemic thinking provides precisely those levers: observing circularity, spotting the regulations — often well intentioned, yet ineffective — and co-constructing other sequences of communication.

Bibliography

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). Washington, DC: Author.

Caligor, E., Levy, K. N., & Yeomans, F. E. (2015). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5), 415-422. https://doi.org/10.1176/appi.ajp.2014.14060723

Denis, P. (2014). Introduction to Paul-Claude Racamier’s paper “On narcissistic perversion.” The International Journal of Psychoanalysis, 95(1), 117-120. https://doi.org/10.1111/1745-8315.12136

Du, T. V., Martinez, M. A., DiGiuseppe, R., & Ghorbani, F. (2022). The relation between narcissism and aggression: A meta-analytic review. Journal of Personality, 90(3), 386-404. https://doi.org/10.1111/jopy.12674

McLean Hospital. (n.d.). Narcissistic Personality Disorder: A basic guide for providers. McLean Hospital/Harvard Medical School. https://www.mcleanhospital.org

Medscape. (2025). Narcissistic Personality Disorder — Overview/Prevalence. Medscape Reference. https://emedicine.medscape.com/article/1519419-overview

Mitra, P., Torrico, T. J., & Fluyau, D. (2024). Narcissistic personality disorder. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.

Oliver, E., Brown, S., & Widom, C. S. (2023/2024). Narcissism and intimate partner violence: A systematic review and meta-analysis. Trauma, Violence, & Abuse. Advance online publication. https://doi.org/10.1177/15248380231151254

Racamier, P.-C. (2012). Les perversions narcissiques. Paris: Payot. (Original works published in 1992 in Le génie des origines.)

Stinson, F. S., Dawson, D. A., Goldstein, R. B., Chou, S. P., Huang, B., Smith, S. M., Ruan, W. J., Pulay, A. J., Saha, T. D., Pickering, R. P., & Grant, B. F. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: Results from the Wave 2 NESARC. Journal of Clinical Psychiatry, 69(7), 1033-1045. https://doi.org/10.4088/jcp.v69n0701

Watzlawick, P., Beavin Bavelas, J., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes. New York, NY: W. W. Norton.

Weinberg, I., & Ronningstam, E. (2022). Understanding and treating narcissistic personality disorder: Recent advances. Harvard Review of Psychiatry, 30(1), 15-28. https://doi.org/10.1097/HRP.0000000000000328

This overview is taken up and developed in the video below — in French.