Narcissism in High-Functioning Individuals – Big Ego or Severe Disorder?

Love seeketh only Self to please,
To bind another to its delight,
Joys in another’s loss of ease,
And builds a Hell in Heaven’s despite.

— William Blake from “The Clod and the Pebble”

Though Blake showed an intuition of the evils of pathological narcissism in the quoted verses, there are certain personality disorders that are easier to spot for the non-professional, because they dramatically hinder the normal functioning of individuals in society. While common people tend to be able to spot a common and identifiable disorder like major depression, which may prevent individuals from going to work and going out, for example, they rarely put a name on certain types of NPD, often dismissing it as just a “big ego” problem.

In fact, narcissists can be huge performers in their professional field, because their inflated sense of self-importance drives them on, to show the world just how important they really are. As society commonly associates personality disorders and psychiatric conditions with the inability to perform and function normally, these high performers may remain undiagnosed for years, and sometimes even for their whole lives. The fact that the scientific community has devoted comparatively little attention to NPD, as opposed to other personality disorders, further boasts its underdiagnosis.

The problem of diagnosis

The bulk of the literature dedicated to narcissistic personality disorders over the last decade has largely focussed on the need to establish new and improved diagnosis models:

The attention to the narcissistic individual’s external, symptomatic, or social interpersonal patterns — at the expense of his or her internal complexity and individual suffering — has also added to the diagnosis’ low clinical utility and limited guidance for treatment. Recent studies and reviews have pointed to the need for change in the diagnostic approach to and formulation of narcissism.

Let’s take a look at the standard diagnosis criteria of NPD, as set forth by the DSM-IV-TR, which defines NPD as:

… an all-pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration or adulation and lack of empathy, usually beginning by early adulthood and present in various contexts.

According to this diagnostic manual, NPD is present when at least five of the following criteria are met:

  • has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
  • is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  • believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
  • requires excessive admiration
  • has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
  • is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
  • lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
  • is often envious of others or believes that others are envious of him or her
  • shows arrogant, haughty behaviors or attitudes

Now, with just a quick glance at this list, I am sure each one of my readers can think of at least a handful of people they know, who seem to meet many of these criteria. Not all of them must, of course, necessarily be suffering from pathological NPD, though some of them might be, and they might remain undiagnosed, due to the fact that the line between pathological and healthy narcissism is an extremely blurry one.

Ronnie Solan dedicated much of her work to attempting to establish these boundaries:

The process of narcissistic self-love is activated by three absolute narcissistic needs: (a) to experience an affective state of well-being (homeostasis) in the familiar and constant state of self-love; (b) to separate the familiar self from the unfamiliar non-self; and (c) to integrate or befriend the unfa- miliar yet “similar enough” non-self within the self in order to contain over-excitation.

Within a healthy narcissistic structure, these absolute needs must reach a state of equilibrium, which means that deciphering the familiar and befriending the unfamiliar (non-self) must be coherent and integral with the genuine identities of familiar self-codes. However, if one of these needs is incoherently regulated in relation to the others, the threat of narcissistic imbalance emerges, further imperiling the integrity of the self-codes.

What Solan calls the “narcissistic imbalance” can appear very elusive to the naked eye of the non-professional observer. The pathological narcissist, with his/her lack of empathy and sense of self-importance will be the last to acknowledge that he/she has a problem. Therefore, the call for help that might bring in a therapist capable of identifying and treating NPD may never come, especially if the individual in question is a high performer, which society tends to view as a sign of personal success.

Expanding the NPD concept

If scholars and clinicians can’t agree on diagnosis criteria, it will be no surprise to find that the general assumptions of society about what constitutes NPD will be rather uncertain. Regarding this issue, a study published in 2008 found certain core features of the disorder which are not included in the DSM-IV’s description of it. These were: interpersonal vulnerability and underlying emotional distress, anger, difficulty in regulating affect, and interpersonal competitiveness.

The same study, which used 200 different criteria to identify NPD patterns, identified three subtypes for the disorder:

  • Grandiose/malignant narcissism (characterized by anger, manipulativeness, thirst for power, exaggerated self importance)
  • Fragile narcissism (characterized by grandiosity as a defensive function, feelings of inadequacy, anxiety, and loneliness.), and
  • High-functioning/exhibitionistic narcissism  ( characterized by individuals being self-important, articulate, energetic, and outgoing.)

The elusive third subtype

It is not casual that one of the authors of the above mentioned study, Drew Westen, PhD, is someone who largely developed on this third subtype of high-functioning narcissists in a previous paper entitled The Relations Among Narcissism, Egocentrism, Self-Concept, and Self-Esteem: Experimental, Clinical, and Theoretical Considerations. Regarding the third subtype, Westen and his colleagues state that:

They tend to show good adaptive functioning and use their narcissism as a motivation to succeed.

High-functioning/exhibitionistic narcissists have relatively good adaptive functioning and less psychiatric comorbidity.

At the same time, they refer to the fact that high-functioning narcissists have received “little empirical attention.” Added to the fact that such individuals generally tend to pass off as “normal” in society, this creates an environment extremely conducive for the underdiagnosis of this type of NPD.

The case of Lara

I now want to refer to a particular case, in order to identify certain behavior patterns that may occur in society around high-functioning narcissists, which contribute to fostering underdiagnosis.

Lara is a performing artist and writer. She has a beautiful singing voice and works as a professional singer. Furthermore, she is her own manager and excels at promoting herself and finding high quality and high-paying gigs. While she is extremely popular with acquaintances, fans, and people she meets casually or online; it is very hard for her to keep a deep lasting friendship or relationship. After a while, people seem to find it rather hard to put up with her conversation, which revolves exclusively around herself and her achievements, without a break, making it impossible for the other person to make a comment. Other than that, Lara is constantly complaining about ways in which the world seems to plot against her, displaying a sense of self-righteousness which people tend to find equally annoying.

As with many other high-functioning narcissists, the problem is: who will advise Lara to seek counseling? It won’t be her friends, because she fails to develop a meaningful friendship, and it won’t be her family either, as Lara comes from a dysfunctional family with a history of domestic violence, with which she has a very superficial relationship. The people she works with dismiss her as someone with a histrionic personality and an inflated ego, plus, she responds very well professionally, so they have no complaints.

Even if Lara came from a healthier family environment, if her relatives didn’t think what she had was pathological, they would probably have a difficult relationship with her, which would create a distance that makes it rather hard to help someone in these matters.

A stranger who met Lara (or any other untreated narcissist of this kind) and became emotionally attached to her might want to help somehow, if he/she had a sense that something was amiss, but the very essence of pathological narcissism shuns every possibility of telling the person that they are wrong about something: we fear that they will be offended and thus, we leave it at that.

If, like Lara, the person in question has been unable to develop deep and meaningful relationships, then there is nobody else we can talk to, and the high-functioning narcissist will roam free, without the slightest possibility of diagnosis, let alone treatment, perhaps, for all their life.


As we can see, both NPD in general and high-functioning narcissism in particular call for further empirical studies, in order to determine a set of revised diagnosis criteria. As regards high-functioning narcissism, it seems to me that there is work to do in terms of educating the public, since the general dismissal of this disorder subtype as a “big ego” problem may be partially responsible for its large underdiagnosis.


Kay J (2008). Toward a clinically more useful model for diagnosing narcissistic personality disorder. The American journal of psychiatry, 165 (11), 1379-82 PMID: 18981068

MILLER, J., CAMPBELL, W., & PILKONIS, P. (2007). Narcissistic personality disorder: relations with distress and functional impairment Comprehensive Psychiatry, 48 (2), 170-177 DOI: 10.1016/j.comppsych.2006.10.003

Ronningstam, E. (2010). Narcissistic Personality Disorder: A Current Review Current Psychiatry Reports, 12 (1), 68-75 DOI: 10.1007/s11920-009-0084-z

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: APA.

Solan, R. (1998). Narcissistic Fragility in the Process of Befriending the Unfamiliar The American Journal of Psychoanalysis, 58 (2), 163-186 DOI: 10.1023/A:1022112416259

Russ, E., Shedler, J., Bradley, R., & Westen, D. (2008). Refining the Construct of Narcissistic Personality Disorder: Diagnostic Criteria and Subtypes American Journal of Psychiatry, 165 (11), 1473-1481 DOI: 10.1176/appi.ajp.2008.07030376

Veronica Pamoukaghlian, MA

Veronica Pamoukaghlian, MA, holds a Masters in Creative Writing. She has directed two documentaries shot in psychiatric wards and a feature documentary about the 77-year old senior Decathlon champion of the world, Raul. Her last production is Monstruo, a short film about non-voluntary euthanasia. She is the CEO of Uruguayan film production company Nektar FIlms. You may visit her blog at The Wander Life
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