The Link Between Narcissistic Personality Disorder and Alcoholism

Narcissistic personality disorder (NPD) and alcohol use disorder (AUD) are closely linked. Both are mental health conditions classified in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), Each damage relationships, cause personal distress, and undermine a person's quality of life and sense of well-being.

NPD and AUD frequently co-exist and can increase the effects of each other. People with a pattern of narcissism often turn to alcohol to reinforce a false sense of grandiosity. People with AUD, also known as alcoholism, can display patterns of narcissism, including self-absorption and an underlying craving for admiration.

This article discusses the similarities and differences between people with narcissistic personality disorder and those with alcohol use disorder. It also discusses ways that they are diagnosed and treated.

Similarities and Differences: Narcissism and Alcoholism

Narcissistic personality disorder is a personality disorder characterized by patterns of narcissistic behaviors. There are two types: grandiose narcissists who have high self-esteem and vulnerable narcissists who have low self-esteem.

Alcohol use disorder is a type of substance abuse disorder where a person cannot control or stop their alcohol use. The symptoms can be mild, moderate, or severe.

NPD and AUD frequently co-occur. According to a 2019 study in Behavioral Medicine, 40.6% of NPD have substance abuse problems. On the flip side, grandiose and vulnerable NPD were both independent factors for alcohol abuse, concluded a 2019 study in the Journal of American College Health.

How They Differ

Personality disorders like NPD are those in which a person has a rigid and unhealthy pattern of thinking, functioning, and behaving. Substance abuse disorders like AUD are characterized by mental and physical addiction.

Both AUD and NPD have distinctive symptoms and features that occur independently of each other.

Where They Overlap

It is not uncommon for two mental health conditions to co-exist (referred to as a comorbidity). The occurrence of two such conditions is called a dual diagnosis.

A dual diagnosis of NPD and AUD is not uncommon. For this reason, mental health professionals will routinely screen for substance abuse when diagnosing a personality disorder or screen for behavioral concerns when a person has a substance abuse disorder.

NPD and AUD overlap in a number of key ways and can reinforce each other. These include characteristics like:

• Avoidant behaviors: People with NPD and AUD find ways to avoid unpleasant or uncomfortable emotions.
• Shifting blame: People with NPD and AUD find ways to blame others or shift responsibility for their own actions.
• Unpredictable behaviors: People with NPD and AUD can respond erratically or exhibit extreme mood shifts.
• Relationship problems: People with NPD and AUD exhibit self-destructive tendencies and have difficulty maintaining relationships both socially and in the workplace.
• Lack of self-control: Despite the harm their behaviors can cause, people with NPD and AUD will persist with the behaviors or feel they have no control over their actions.
• Prior trauma: People with NPD and AUD are often victims of past sexual, physical, or emotional abuse or neglect. This includes living with someone with a mental illness or addiction.
• Distress: Despite avoidance behaviors, NPD and AUD are ultimately characterized by deep feelings of distress and anxiety.
  

Challenges in Diagnosis

Making a dual diagnosis of NPD and AUD can be challenging and something that only a qualified mental health professional can make.

Exhibiting narcissistic behaviors when drunk, for example, doesn’t inherently mean that a person has NPD. Alcohol can influence narcissistic behaviors, such as arrogance, self-importance, and feelings of superiority that aren’t otherwise present when sober.

Similarly, using alcohol doesn't mean a person with NPD has AUD, even if there have been incidents of extreme intoxication.

All personality and substance abuse disorders are diagnosed based on a strict set of criteria described in the DSM-5. While there is room for interpretation, a person with NPD and/or AUD must meet a minimum standard before a diagnosis can be delivered with confidence.

By way of example, a person must meet five of nine possible criteria for NPD to be diagnosed, ranging from grandiosity to a lack of empathy. For AUD to be diagnosed, a person must meet one of four possible criteria for alcohol abuse, three of seven possible criteria for alcohol dependence, and two of 12 possible criteria for AUD symptoms.

Moreover, each mental health condition must be independently diagnosed. By doing so, a person is less likely to be "over-treated" for a condition they may not actually have.

One example is being referred to Alcoholics Anonymous (AA) on the presumption of AUD. In such cases, a person might start to question the diagnosis and abandon treatment altogether even if another condition, such as NPD, actually exists.

Challenges in Treatment

The treatment of NPD and AUD should ideally be delivered simultaneously, especially if there is severe addiction or depression. With that said, there are challenges to delivering appropriate care for the dual diagnosis.

For instance, NPD and AUD both involve psychotherapy, but the formats for each can vary. For NPD, it may involve individual or group counseling using cognitive behavioral therapy, schema-focused therapy, and dialectical behavior therapy. For AUD, group approaches such as AA and other twelve-step addiction programs are common.

Treating each condition independently can sometimes lead people to "choose one over the other," especially if care is not coordinated. This is especially true if medications are prescribed.

With NPD, for example, there are no drugs specifically used for the treatment of the personality disorder, but antidepressants or anxiolytics may be prescribed if depression or anxiety is present.

On the other hand, the treatment of AUD can involve several different drugs such as benzodiazepines to treat anxiety and insomnia, Topamax (topiramate) to treat alcohol dependence, Campral (acamprosate) to ease alcohol withdrawal, and Revia (naltrexone) to reduce alcohol cravings.

Again, if care is not coordinated by a qualified mental health professional, the overlapping treatments can lead to drug interactions, unintended side effects, and the possible abandonment of treatment.

Where to Find a Support System 

Finding the right support system is important when dealing with co-occurring disorders or helping someone who has NPD, AUD, or both. 

As Someone With NPD and AUD

To get the support you deserve, you’re going to need to seek professional help. Admitting there’s a need for help is the first hurdle. Finding the appropriate mental health and addiction professionals is the next hurdle.

Change is possible with help. You can find support by speaking with your healthcare provider about what you’re noticing or what others have told you. For example, maybe you’re considering seeing a healthcare provider because your spouse says you’re a narcissist who drinks too much and they won’t stop asking you to get help. It may be a good idea to slow down and, keeping in mind no one is perfect, really listen to what your spouse is saying and how your healthcare provider responds.

If you’re not quite ready to talk to someone about narcissism or alcohol use, and if you’re wondering if your relationship with alcohol is healthy, there are many online assessments you can take to let you know where you sit on the spectrum of narcissistic traits and drinking behaviors. These are not diagnostic tools but can be helpful to give you an idea so you can have an honest conversation with yourself and, when ready, your healthcare providers.

AA and other 12-step programs can also provide a valuable added layer of peer support for people quitting or cutting back on their drinking. Exact outcome data is hard to determine due to the anonymity of the programs.

Online “closed groups” and public groups, as well as apps that track usage or money saved and health benefits since quitting, like I am Sober, Sober Tool, and Sober Grid, are also useful to people seeking more support or reward replacements.

As the Partner or Family Member

If you’re the partner of someone with NPD and AUD, you likely witness and hear things the narcissist’s family and friends don’t. Understandably, this can make it difficult to seek support from them or convince them of a need for intervention. Your partner may also have surrounded themselves with people who feed their narcissism with praise, admiration, and constant validation (people pleasers).

You may want to begin with peer support groups for family members of alcoholics (Al-anon) and/or support groups for people in a relationship with a narcissist or narcissist abuse support groups. These groups are offered in-person and online.

Whether you decide to stay in the relationship or leave but are involved through shared children, getting support for yourself is essential. Being with a narcissist is emotionally exhausting and may leave you drained and feeling like you’re walking on eggshells.

Seeking outside support from your social network or professionals can help you manage these feelings.

If you are being physically, emotionally, or sexually abused, know that there is help available. Take a moment in a safe location like a public washroom to create a plan for safety at the Domestic Violence Hotline so you’re prepared if or when you decide to leave. If you’re in immediate danger, please dial 911. 

Summary

NPD is a personality disorder and AUD is an addiction. While different, they can co-occur and they share similarities. People with NPD and AUD may avoid taking responsibility, have a lack of self-awareness, live with grandiosity, and may be practiced at manipulating others to get their own way.

Treatment is best approached as a team effort to cope with both disorders. Relapse can occur, but doesn’t mean hope for change is lost.