Malignant Narcissistic Personality Disorder

Although malignant narcissistic personality disorder (MNPD) is not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), it is used by many clinicians to describe a subtype of narcissistic personality disorder (NPD).

Campbell’s Psychiatric Dictionary states that MNPD combines characteristics of Narcissistic Personality Disorder (NPD), Antisocial Personality Disorder (APD), aggression, sadism and paranoia.

Let’s take a look at these separately.

What is Narcissistic Personality Disorder (NPD)?

A person with a narcissistic personality disorder is one who has a desire for admiration and has an over-inflated sense of worth, knowledge, power, or identity. They must possess at least five of the following characteristics.

  • Has feelings of entitlement.
  • Seeks admiration.
  • Has an exaggerated sense of self-importance.
  • Appears outwardly arrogant.
  • Is preoccupied with beauty, success, power, or brilliance.
  • Lacks empathy. Is unable to identify with the feelings of others.
  • Exploits others for personal gain.
  • Wishes to only associate with others who are successful.
  • Is envious of others and may believe others are envious of him/her.

NPD patients depend on positive feedback from others. If they don’t receive admiration, these individuals may become angry, anxious, or depressed.

It is common for those with NPD to be controlling. They often detach emotionally from others and have minimal or no concern regarding the impact of their behavior.

The opinions and views of others are ignored if they differ from their own. They do not respond well to change and are insecure and vulnerable. These people tend to have a difficult time managing their emotions and responding to stress.

It can be challenging to diagnose this condition because of the difference in presentation between individuals. Some may be shy and avoid contact with people, while others are grandiose and outgoing.

The critical thing to remember is these people have little self-esteem and have problems regulating their emotions.

Antisocial Personality Disorder (APD)

People with Antisocial personality disorder have little to no empathy. They often abuse others both physically and emotionally. Diagnosis of APD is made after at least three of the following are present:

  • Inability to follow through on commitments or obligations.
  • Use of deceit, seduction or charm to achieve goals
  • Inability to conform to cultural norms or lawful, ethical behavior.
  • Lack of remorse for others suffering.
  • Persistent or frequent anger or aggressive behavior.
  • Seeks immediate gratification and is impulsive.
  • Engages in risky, dangerous, and self-damaging activities.



Aggression is not a condition but a behavior. It generally occurs in response to anger. Aggression is a hostile or violent behavior or attitude directed toward another person. Many factors may contribute to aggression, including mental health, family structure, relationships, environment, and family structure.


Sadism is the tendency to derive pleasure from inflicting pain, suffering, or humiliation on others. This pleasure is often sexual in nature.

How is NPD Treated?

The first-line treatment of all personality disorders is psychotherapy. For MNPD, cognitive therapy is the starting point. The recommendation is to offer group-based cognitive and behavioral interventions to target impulsivity, antisocial behaviors, and interpersonal weaknesses.

The use of medication is reserved for specific behaviors related to cluster B personality disorders:

Anticonvulsants/mood stabilizers – These may be used for impulsive and violent behavior, although there is limited data to support their use.

Lithium 1200 mg/day (target level = 0.6-1.5 mEq/L)

Phenytoin 300 mg/day

Divalproex 750 mg/day

Carbamazepine 450 mg/day

Stimulants such as methylphenidate have been used for inattention, impulsivity, and irritability. There is a high risk of abuse, so these medications are rarely used.

SSRI’s can be useful for aggression, hostility, and impulsivity.

Sertraline – 25-50 mg/day titrated slowly to 150-200 mg/day.

Fluoxetine – 20 mg/day slowly titrated to 60-80 mg/day.

Benzodiazepines should only be used in crisis situations due to abuse potential and an increased risk of suicide in these individuals.

Malignant narcissistic personality disorder is a condition brought about by emotional dysregulation. They have a fragile ego and must receive positive feedback from others. These individuals can be dangerous when things don’t go their way. Many have little regard for the feelings of others and often are controlling. They often exploit others for their own personal gain.

Unfortunately, most of these people will not seek treatment because they believe the problem stems from others. They have an exaggerated sense of self-worth and prefer to be surrounded by influential people. They are shallow when evaluating others and often put too much emphasis on looks.

Personality disorders are the most difficult psychiatric conditions to treat because they are the result of coping mechanisms created over many years. The only hope is to retrain these individuals to react to their environment in a healthy way. Group therapy is often the best method of achieving this.

Medications can be helpful for specific symptoms, but I have observed little success of medications used for personality disorders.

If you are in a relationship with a narcissist, be sure to protect yourself. These individuals can be dangerous and may get gratification from hurting you. Follow your instincts. If you feel threatened, get out of the relationship.

Remember, people with mental illnesses are no different than those with heart disease, diabetes, or cancer. They have a disorder that affects the brain. As a society, it is our responsibility to take care of them. If we don’t, we will all suffer the consequences.

If you have any questions, please send me an email. This is a difficult but important subject. Be healthy, be happy, and most importantly, be safe!




Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.



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