periences often lead to social withdrawal or an appearance of humility that may mask and
protect the grandiosity. Interpersonal relation s are typically impaired because of problems
derived from entitlement, the need for admira tion, and the relative disregard for the sen-
sitivities of others. Though overweening ambition and confidence may lead to high
achievement, performance may be disrupted beca use of intolerance of criticism or defeat.
Sometimes vocational functioning can be very low, reflecting an unwillingness to take a
risk in competitive or other situations in wh ich defeat is possible.  Sustained feelings of
shame or humiliation and the attendant self-criticism may be associated with social with-
drawal, depressed mood, and persistent depr essive disorder (dysthymia) or major de-
pressive disorder. In contrast, sustained periods of grandiosity may be associated with a
hypomanic mood. Narcissistic personality disorder is also associated with anorexia ner-
vosa and substance use disorder s (especially related to cocaine). Histrionic, borderline,
antisocial, and paranoid personality disorders may be associated with narcissistic person-
ality disorder.
Prevalence
Prevalence estimates for narcissistic person ality disorder, based on DSM-IV definitions,
range from 0% to 6.2% in community samples. 
Development and Course
Narcissistic traits may be particularly comm on in adolescents and do not necessarily in-
dicate that the individual will go on to have narcissistic personality disorder. Individuals
with narcissistic personality disorder may have special difficulties adjusting to the onset of
physical and occupational limitations that  are inherent in the aging process. 
Gender-Related Diagnostic Issues
Of those diagnosed with narcissistic personality disorder, 50%–75% are male.
Differential Diagnosis
Other personality disorder s and personality traits. Other personality disorders may