Despite outward signs of grandiosity, many people with NPD struggle with symptoms of intense shame, worthlessness, low self-compassion, and self-loathing.[12][13] Their view of themselves is extremely malleable and dependent on others' opinions of them. They also are hypersensitive to criticism and possess an intense need for admiration.[14][15][16] People with NPD gain self-worth and meaning through this admiration.[17][18] Individuals with NPD are often motivated to achieve their goals, status, improvement, and perfectionism, and to ignore relationships or avoid situations due to fears of incompetence, failure, worthlessness, inferiority, shame, humiliation, and losing control.[13][7]
People with NPD will try to gain social status and approval in an attempt to avoid and combat these feelings,[19] often by exaggerating their skills, accomplishments, and their degree of intimacy with people they consider high-status.[20][21][22] Alongside this, they may have difficulty accepting help,[23] vengeful fantasies, a sense of entitlement,[21][24] and they may feign humility. They are more likely to try forms of plastic surgery due to a desire to gain attention and to be seen as beautiful.[2][25][26] A sense of personal superiority may lead them to monopolize conversations, look down on others or to become impatient and disdainful when other persons talk about themselves.[2][12] Drastic shifts in levels of self-esteem can result in a significantly decreased ability to regulate emotions.[27]
Patients with NPD have an impaired ability to recognize facial expressions or mimic emotions, as well as a lower capacity for emotional empathy and emotional intelligence.[28][29] However they do not display a compromised capacity for cognitive empathy or an impaired theory of mind, which are the abilities to understand other's feelings and attribute mental states to oneself or others respectively.[30] They may also have difficulty relating to other's experiences and being emotionally vulnerable.[31] People with NPD are less likely to engage in prosocial behavior.[31] They can still act in selfless ways to improve other's image of them, advance their social status, or if explicitly told to.[32] Despite these characteristics, they are more likely to overestimate their capacity for empathy.[33]
It is common for people with NPD to have difficult relationships.[34][35][36][37] Narcissists may disrespect other's boundaries or idealize and devalue them. They commonly keep people emotionally distant, and project, deny,[38] or split. Narcissists respond with anger and hostility towards rejection,[39][34][40] and can degrade, insult, or blame others who disagree with them.[41][42]
They generally lack self-awareness, and will have a difficult time understanding their own traits and narcissistic tendencies, either due to a belief that NPD characteristics do not apply to them, or due to a refusal to accept or endorse negative characteristics in an attempt to maintain a positive self image.[43][44] Narcissists can have difficulty seeing multiple perspectives on issues and black and white thinking.[45] Despite this, people with NPD will often feel as they are skilled at accurately assessing others' feelings.[46]
