Claire is 47, a mother of two, and recently divorced. Her ex-husband, Dan, 58, was a successful businessman when they met 12 years ago. “By the time we separated,” she says, “I no longer knew what was true and what was a lie. I was emotionally battered, my confidence was in shreds, and I felt the person I had once been had somehow been sucked out of me by Dan’s bullying and manipulation.”

A friend studying to be a psychotherapist suggested she look up narcissism on the internet. “I began reading everything I could, and that led me to narcissistic personality disorder [NPD]. It made me realise that not only me but a couple of friends had experienced something similar in their relationships. NPD is said to be particularly prevalent among the driven and ambitious.

“At first, I thought Dan was a really secure guy, with normal values and objectives. A person with NPD will be whatever you want him to be – as long as it suits him. Then, suddenly, you’re in exile, and you’re left perplexed, blaming yourself for what you’ve apparently done wrong. I was either worshipped or, more often, undermined. At the same time, whatever traits you have that he finds attractive – and therefore threatening to his own sense of superiority – he will set out to destroy.

“As the marriage progressed and I discovered more of his lies, the angrier he became and the more he drank,” Claire recalls. “I begged him to get help for the sake of the children – not realising that the root of the problem was probably NPD.”

Dan agreed, but later Claire found out that the time he was supposed to be spending in alcohol-addiction centres and on anger-management courses, he was with his girlfriends. “Healthy narcissistic tendencies are life-preserving,” she says. “But when the narcissism is extreme, it’s hugely destructive to everyone around. It’s a form of emotional abuse that isn’t properly recognised yet, and it ought to be. Narcissists play a subtle, long-term psychological game that is truly deadly to the other person’s psyche.”

Claire is one of a growing number of people in Britain who are convinced their partner, boss or one of their parents has NPD.

Although Freud published his study On Narcissism in 1914, NPD wasn’t officially recognised as a personality disorder in the US until the 1980s. Seen as the high-flyers’ disease, often allied with drugs, gambling and alcohol abuse, it is now a multi-billion-dollar industry. There are hundreds of therapists and support groups for the children, employees and partners of people with NPD, as well as websites and self-help books with titles such as Help! I’m in Love with a Narcissist and Children of the Self-Absorbed: A Grown-Up’s Guide to Getting over Narcissistic Parents.

In the UK, there has been an ambivalent response to the apparent problem. Partly because, for a number of years, some psychiatrists questioned whether NPD and other personality disorders existed at all, while others believed they were simply untreatable. The change came in the 1990s, spurred by the government’s growing concern for the safety of the public after several attacks by people suffering from “severe and dangerous” personality disorders, and demands that they should be treated.

So what exactly is NPD? How easy is it to distinguish between a badly behaved rogue who may really love you – and a man, or woman, who has become highly skilled in camouflaging their lack of authentic emotion? And is there a cure?

In Greek mythology, Narcissus, the handsome young Thespian, epitomises the concept of destructive self-love. According to the legend, Echo the nymph falls in love with Narcissus, but since she has been stripped of the ability to form her own words, she can only repeat what she hears. Narcissus, enamoured of his image reflected in a pool, addresses himself and says, “I love you,” repeated longingly by Echo. Narcissus, however, is too self-absorbed to see, hear or react. He eventually dies of languor, neglecting to eat or drink. Echo dies from a broken heart.

In the myth, falling in love with one’s own image is seen as punishment for being incapable of loving another. In reality, NPD, at its most extreme, can lead to murder. In 2004, the public-school boy Brian Blackwell, 19, stabbed and bludgeoned his parents to death at their home in Merseyside before embarking on a £30,000 spending spree. He was obsessed with fantasies of success, power and brilliance, claiming, for instance, that he was a world-class tennis player. He was diagnosed as suffering from NPD.

NPD appears to affect men more than women. A person with NPD is spectacularly lacking in curiosity or concern for others, but can easily simulate both if it ensures the continuation of what psychiatrists call “the narcissistic supply” of uncritical admiration and adulation.

In Narcissism: Denial of the True Self, first published in 1985, the American psychiatrist Dr Alexander Lowen refers to the case of Erich, brought to him by his girlfriend, Janice. Dr Lowen asks Erich about his feelings. “Feelings!” Erich replies. “I don’t have any feelings… I programme my behaviour so that it is effective in the world.”

Erich describes his mother as perpetually on the verge of hysteria, provoked by a father who was cold and hostile. Dr Lowen diagnoses that Erich has deadened his emotions in response to his parents’ dysfunctional relationship. He writes: “The narcissistic image develops in part as a compensation for an unacceptable self-image and, in part, as a defence against intolerable feelings… a state of living death.” Erich, in his relationship with Janice, has continued to shut down feeling while exercising power. “He got her to love him without any loving response on his part,” Dr Lowen explains. “Such exploitativeness is common to all narcissistic personalities.”

So, how do you know if a person has NPD? Mental-health professionals in Europe and the US draw on two sets of guidelines that are regularly updated by international groups of psychologists and psychiatrists to help make a diagnosis. The ICD-10, the World Health Organization’s classification of mental and behavioural disorders, published in 1992, lists nine categories of personality disorder, but does not include NPD.

In the US, the Diagnostic and Statistical Manual of Mental Disorders was first published by the American Psychiatric Association in 1952, in part to provide a benchmark for insurance companies handling medical claims. The fourth and current version (DSM-IV), published in 1994, lists 10 categories of personality disorder (see page 27) of which NPD is one. (DSM-V is due to be published in 2010.) DSM-IV also gives a list of nine characteristics, of which a person has to have at least five before NPD is considered.

The nine include a grandiose sense of self-importance; preoccupations with fantasies of success, power, brilliance, beauty or ideal love; a belief that he or she is “special”, only understood by other “special” people; a need for admiration; a sense of entitlement or unreasonable expectations of favourable treatment; exploitative, taking advantage of others to achieve his or her own ends; unwillingness to recognise or identify with the needs of others; envious of others, or thinks others are envious of him or her, and arrogance.

In its most extreme form, known as malignant narcissism, paranoia and physical aggression may also be displayed: Stalin, Hitler and Saddam Hussein come to mind. In the rich and successful, many of the characteristics of NPD are of course seen as positive attributes. In a 2005 study, the psychologists Belinda Board and Katarina Fritzon at Surrey University found that three personality disorders, including NPD, were more common in managers than in criminals.

In an article in The New York Times, Board explained: “A smattering of egocentricity, a soupçon of grandiosity, a smidgen of manipulativeness and lack of empathy, and you have someone who can climb the corporate ladder and stay on the right side of the law, but still be a horror to work with. Add a bit more of those characteristics, plus lack of remorse and physical aggression, and you have someone who ends up behind bars.

“What’s important is the degree to which a person has each ingredient or characteristic, and in what configuration.”

Since many people may belong to more than one category of personality disorder, DSM-IV divides the categories into three clusters. NPD belongs to Cluster B – dramatic, emotional or erratic types, embracing histrionic, narcissistic, antisocial and borderline personality disorders.

“The characteristics and categories provide clues, but not a definitive diagnosis,” says Professor Eddie Kane, the director of the Personality Disorder Institute at Nottingham University. “While it’s clear when a person is psychotic or schizophrenic, we have to be wary in diagnosing personality disorder. Putting a label on someone’s behaviour that may have an enormous impact on their lives has to be very carefully considered.”

In a paper published this May in The British Journal of Psychiatry, Professor Peter Tyrer and colleagues from the department of psychological medicine at Imperial College London wrote unequivocally: “The assessment of personality disorder is currently inaccurate, largely unreliable, frequently wrong and in need of improvement.”

And the psychiatrist Dr Paul Moran of the Institute of Psychiatry in London, the author of several papers on personality disorders, says: “A number of biases can distort the assessment of personality. For instance, there is evidence to suggest that the term “personality disorder” may itself be a label applied to unlikable patients who are regarded as difficult. A person can be supremely confident, superficially charming, and only choosing to treat people as stepping stones in his life. But does that mean he’s displaying signs of NPD? At present in the UK, our understanding of the characteristics, causes and treatment of NPD are very rudimentary. It’s still only a theory about how some people might behave. However, I have no doubt that individuals can and do manifest these traits.”

In 2006, a team that included Professor Jeremy Coid of the forensic-psychiatry unit at St Bartholomew’s Hospital, London, published an assessment of the prevalence of personality disorders in Great Britain in the British Journal of Psychiatry. The study concluded that they are “common”, affecting nearly 1 in 20 people (4.4%) – previous estimates have given a higher figure of 10-13%. What the study failed to find, however, was a single case of NPD. (DSM-IV estimates that about 1% of the US population has NPD.)

“That does not mean it doesn’t exist in the UK,” Professor Coid says. “The questionnaires used to pick it up do not work very well because not many people admit to these criteria. People don’t like to admit they are arrogant and envious.”

One reason why people with NPD appear few in number is that they are treatment resistant. Put plainly, they don’t believe they have a problem, so they rarely present themselves for help.

Shmuel “Sam” Vaknin, 46, has been diagnosed with narcissistic personality disorder twice. He is unusual in that he accepts the diagnosis, uniquely turning it into a way to provide an international source of narcissistic supply. Born in Israel, since the mid-1990s he has written extensively about himself and NPD, both on the internet and in books, including his magnus opus, Malignant Self Love – Narcissism Revisited. Hundreds interact daily on his websites. He insists that he offers help and advice only to ensure a narcissistic supply of attention that confirms his superiority, intelligence and specialness – not because he cares.

Vaknin is an unsettling combination of the chilling and the charming. In conversation, it’s hard to disentangle truth from the narcissist’s tools of the trade – exaggeration, flattery, grandiosity and the display of fake vulnerability and self-pity to elicit sympathy. He is a verified economist, award-winning writer, poet, philosopher, journalist and financial consultant. He is also, he says, a failure. On one of his websites, he writes: “I have lived in 12 countries, worked in 50, and I don’t think there is one that will take me back. I consider the businesses I drove to bankruptcy with my narcissistic temper tantrums and superiority contests… The fortunes I squandered… I cherished and revelled in my self-annihilation.”

Vaknin lives in Skopje, Macedonia. He is one of five siblings, but he hasn’t seen his family for over a decade. His father was a construction worker from Morocco, who suffered from clinical depression. “Violence was the main channel of communication,” Vaknin says. His mother was from Turkey. She believed she was a prodigy, but had to leave school and sell shoes to rich people at the age of 14. “I have an IQ of 180 and it was her enormous misfortune to have me as her first-born,” Vaknin says. “My parents were ill-equipped to deal with normal children, let alone the gifted. I was her ambassador to the world, but I also constituted a threat.” Vaknin says his mother is a narcissist. In a short story – Nothing’s Happening at Home – fiction based on his own childhood, he describes the life of a six-year-old with a violent, resentful and unpredictable mother. “ …mother takes a broom to me and beats me forcefully on the back and all the neighbors [sic] watch… on the floor is this large yellow puddle in which I stand. Mummy’s broom gets all wet and the neighbors [sic] laugh… She takes down my trousers and I am exposed to the jeering crowd, drenched and naked. It isn’t a good day, this one”.

“Children with narcissistic parents are objectified. They are like circus animals, performing on order, to extract a little love,” Vaknin says. “I don’t hate my mother. I hate what her illness did to her. I began to live as if life is a film and I’m playing out a script, totally detached to fend off hurt and injury. Now, I am a monster. Underneath the skin, I am a hideously deformed individual. When you look at the quadriplegic, you can understand if he can only wink – the quadriplegic is a marathon runner compared to me and my emotional disability.”

At 17, Vaknin left home to join the army and never returned. He was first diagnosed with NPD at 26. He was living in opulence in London with his then wife, Nomi. On her insistence, he visited a psychiatrist. “When I first received the diagnosis, I was mortified and very frightened. Then, as a typical narcissist, I thought, ‘Can I use the diagnosis as leverage to become famous? Make money?’ The answer was yes.”

In 1995, Vaknin was diagnosed for a second time by a psychiatrist in an Israeli jail. He was serving 11 months for fraud, trying to manipulate the price of stock. In jail he began to write Malignant Self Love – Narcissism Revisited.

“I am no healthier today than I was when I wrote that book. My disorder is here to stay, the prognosis is poor and alarming. The vast majority of narcissists end up at the very top or the very bottom – derelict, desolate, schizoid, bitter, decaying and decrepit. You won’t find any in the middle. My narcissism is much worse than it used to be. As my capacities dwindle, minute by minute, the gap between reality and grandiosity becomes bigger and bigger. The larger the gulf, the more narcissistic defences are needed.

“I am an abject failure in comparison to my potential. I should have been a public intellectual. But people don’t like looking in the mirror, and I like forcing them to look.”

Vaknin has been married to his second wife, Lidija, 37, for five years, and they have been together for 10. She is Macedonian. Lidija would like a child. In response, Vaknin says he is a cerebral narcissist, relying on his intellect to attract a narcissistic supply. He is not much interested in sex. “For Lidija, our relationship is a constant war of attrition,” Vaknin says. “I think she is very tired. She says sometimes she is being erased. But she stays, so I must respond to some of her emotional needs. A narcissist infiltrates his partners like acid,” he explains. “If she fails to erect strong defences, the narcissist takes over, forcing the eviction of the person’s original self.”

Vaknin says narcissism recruits as it infects. “Narcissism creates a bubble universe similar to a cult. In the bubble, special rules apply that do not always correspond to an outer reality. The narcissist conditions people, so the victims come to assimilate the narcissist’s way of thinking. You can abandon the narcissist but the narcissist never abandons you. We are like body snatchers.”

Lidija Vaknin appears undaunted. “Some people think I’m crazy to stay with him, but I’ve discovered I am strong. At the beginning, several times a day, I wanted to leave. Now, it’s easier. My father was a narcissist and very physically abusive. My previous partner was violent. I learnt to read the eyes, the mouth, the body language. I don’t feed Sam’s need for admiration. We talk and tackle the issue. Sometimes I have to repeat what I say many times, and sometimes I give up trying.

“On occasions, he is untouchable. If he’s in that state, I don’t even try to communicate. He has his own world, and if I try to enter it, he explodes into many pieces. We are a good match. Sam is clever and funny. He makes jokes about himself, which is rare for a narcissist.”

Lidija’s sister, Meri Petrov, says of Vaknin: “I’ve never met a man like him. He knows how to be a good friend, but one minute everything is going well, then suddenly he says horrible things and has a terrible anger. One minute he’s kind, the next I can’t define him. My sister has found a way to live with him, I don’t know how.”

Vaknin believes his NPD was triggered by childhood trauma and abuse. “Every human being develops healthy narcissism. That is rendered pathological by abuse. By ‘abuse’ I mean refusal to acknowledge the emerging boundaries of the individual. Smothering, doting and excessive expectations are as abusive as beating and incest.”

Dr Bob Johnson, consultant psychiatrist and co-founder of the James Nayler Foundation to further research into personality disorders, agrees. “Personality disorders are all to do with software. The trauma a person has experienced in childhood. They have nothing to do with predispositions or genetics or the type of society in which a person lives. Address the trauma and the personality disorder evaporates. But the individual first has to want to change.”

Professor Eddie Kane disagrees. He says the causes of personality disorders, including NPD, may turn out to be “multi-factorial”. Biological, psychological and social-risk factors may have differing impacts on different individuals. Dr Joel Paris, professor of psychiatry at McGill University, Montreal, suggested 10 years ago that: “Personality disorders are pathological amplifications of normal personality traits… different social structures tend to reinforce some traits and discourage others.” The DSM-IV definition of personality disorder refers to behaviour “that deviates markedly from the expectations of the individual’s culture” – but could a narcissistic culture act as a hothouse for NPD?

The American Dr Theodore Millon is an internationally renowned psychologist and psychiatrist. In Personality Disorders in Modern Life (2000), written with Roger Davis, he argued that pathological narcissism gained prominence only in the late 20th century. “Individuals in less advantaged nations… are too busy trying (to survive) to be arrogant and grandiose.” Millon and Davis attribute pathological narcissism to “a society that stresses individualism and self-gratification at the expense of the community, namely the United States”. Others see western culture devaluing and undermining the very elements, home and family life, work, self-reliance and healthy personal relationships that act as protective factors against narcissism.

An extensive study showing the significant growth of narcissism in the US was published earlier this year. Headed by Jean Twenge, professor of psychology at San Diego State University, it assessed the responses of 15,234 college students, between 1987 and 2006, to a test called the Narcissistic Personality Inventory. It attempts to rate changes in areas such as self- esteem, assertiveness and whether individuals see themselves as leaders. As part of the inventory, students are asked to agree or disagree with statements such as, “I think I am a special person.” The study found, “an alarming rise in narcissism and self-centredness”. It discovered that the average college student scored higher in narcissism than 65% of students 19 years earlier. “We’ve seen a distinct increase in narcissism,” Twenge says. “Is some of it healthy narcissism? I’m not sure there is such a thing.”

Twenge is also the author of Generation Me: Why Today’s Young Americans Are More Confident, Assertive, Entitled – and More Miserable than Ever Before, published last year. “The rise in narcissism has very deep roots,” Twenge says. “We fixate on self-esteem and unthinkingly build narcissism because we believe the needs of the individual are paramount.”

Yet, in highly narcissistic societies, millions do not develop NPD – why not? The psychologist Dr Jeffrey Young suggests an antidote might be: “Unconditional parental love that includes fair and firm boundaries, consistent discipline and a resistance to the inclination to spoil.”

In one study, however, NPD was also found in countries in Asia and Africa – so is it truly a modern disease of the affluent? Or is Sam Vaknin correct in believing it has always existed, whether among “subsistence farmers in Africa or intellectuals and socialites in Manhattan”? As the causes are, as yet, unclear – can NPD be cured?

Dr Young founded the Schema Therapy Institute in New York more than 20 years ago. It integrates elements of cognitive behaviour therapy and gestalt therapy to identify and change self-defeating life patterns that he calls “schema”.

Dr Young’s methods have had some recognised success with NPD and other personality disorders, previously regarded as untreatable. Schema therapy is based on the notion that we all have different parts of the self, known as “modes” (eg, easygoing, angry, carefree, focused). For people with personality disorders, these are more extreme and rigid, making it difficult for a person to move from one mode to another.

In therapy, Young tries to engage “the lonely shamed child” that he sees as the source of the pain for an individual with NPD. All of which is difficult to achieve, because even if a person agrees to treatment, Young points out dryly, he may walk out unless the therapist keeps telling him he’s simply the best; ordinary won’t do.

“A lot of people only come because they’ve been sent by desperate partners or bosses. Successful narcissists have something extra that means people tolerate their bad behaviour. The most dangerous is the unsuccessful narcissist. He doesn’t have money or power or charm, so he’s fired a lot of the time. He drives more and more people away, until he ends up alone and a very bleak person.”

In treatment, people diagnosed with NPD are divided into two groups. In one are “pure” or thick-skinned narcissists. They have often been extremely spoilt and indulged and given no boundaries as children. In the second group are thin-skinned narcissists, such as Vaknin, who have grown up feeling unloved and unlovable. Young says the former are almost impossible to help; the latter may respond to therapy. “If there’s no change in a year, the chances of success are low. The person with NPD will constantly try to prove he is superior to the therapist; that the professional knows nothing.”

Treatment may also involve drugs to combat additional mental-health problems such as depression. “Perhaps a lot of what we’re doing is completely wrong,” Professor Conor Duggan, head of forensic mental health at Nottingham University, says bluntly. “Sometimes in mental health, doing nothing is better than doing something, but the imperative at present is to act. Without good-quality, rigorous clinical trials, we can’t come up with proof of efficacy – but investment in mental-health research is paltry in comparison to, say, cancer. It’s vital that that changes.”

I spoke to several psychiatrists about what a person should do if he or she believes a partner has NPD. The response was unanimous: “Leave.” “The children of narcissists may find themselves attracted to narcissists, because they have had an early training,” says Dr Michael Isaac, consultant psychiatrist and senior lecturer in psychological medicine at Guy’s, King’s and St Thomas’s medical schools in London. “But for other women, what often happens is a dovetailing of needs. A woman may feel a sense of service and self-abnegation. Or she may entertain the notion that she is his chosen one. It’s only later the pleasure becomes pain.”

Claire has no regrets about making her break. Her ex-husband, Dan, rejects the suggestion that he has NPD. “If you have a lot invested in your choice of man, denial about his behaviour is easy. I thought it was my fault I couldn’t reach him. Learning about NPD put together a lot of the pieces in our marriage that had refused to fit before. I now know, if you’re living with someone who has the disorder, whatever you do will never be enough. Be warned.”

Some names and personal details have been changed to protect identities

Carla, 40

Carla, 40, an only child, is divorced with a 12-year-old-son. Her mother, in her late sixties, is French. Carla’s parents separated when she was young, and she had little contact with her father. Carla went into therapy two years ago, and now believes her mother has NPD.

‘If your mother is a narcissist, it’s like living with a child who expects you to be their doll, discarded when they lose interest. I only now realise the full extent of the damage she did. Yet my instinct is still to please her. I still live five minutes away and do as she demands.

‘My therapist told me to “Laugh, let go and feel free”. I honestly don’t know how to do that because I’ve been conditioned to think only of what my mother wants from me.

When I was a child, my mother used to talk to others about me in a disparaging way — in front of me. I always had to say, “Mama, Mama”, five or six times before she paid any attention — she was completely self-absorbed. She’s like a sponge. She soaks up what she needs. When she’s satiated, she can be unbelievably cruel. Now I know it’s a disease, I feel sorry for her.

‘I never finished my education. My mother was a successful academic, but I don’t think she wanted to risk me outshining her. So I’ve drifted through life. I married young and went for what was familiar. My husband was charismatic, domineering, narcissistic, and he put me down — everything I was used to. He had an affair, so I divorced because my mother told me to. I got married again, to a decent man, but I was so used to extreme emotions I got bored.

‘My therapist asked me where I saw myself in two years’ time. The thought had never occurred to me that I had the right to think like that. That’s what narcissism does to another human being. I’d love to meet others who have had the same experience and come through it. Maybe they can show me how to live like a human being who isn’t in a form of bondage that nobody else can see.’

Leonie, 32

Leonie, 32, in advertising, met Tom, 36, four years ago. ‘He was charming and made me laugh. Within months he proposed. Then we moved in together, and he began to change. If I said I was going for a run, he would sulk. Or he would go into a fury if I’d arranged to see friends. For the sake of peace, I stopped exercising, stopped living my own life. I was sure he was having an affair, but he said I was being neurotic. I then found out he’d been married before. He said he hadn’t told me because he didn’t know how I’d react. I ended up feeling sorry for him. He was so clever at manipulation.

‘When we met, I was confident and outgoing, with a good circle of friends. By the time I left, I’d dropped three dress sizes. I was insecure, anxious, isolated and on antidepressants. I’d almost lost all sense of myself.’

Leonie later found out she was not the only woman to leave a relationship with Tom in a very different state from how she entered it. She was contacted through mutual friends by Kate, 33, an architect. ‘Kate was a mirror image of myself when I first left,’ Leonie says. ‘She was gaunt, depressed and tearful.’ Kate’s story was familiar. A proposal after a few months; mood swings; affairs; emotional cruelty; jealousy. She walked out, but not before going through his e-mails. He boasted of earning £70,000 a year. She found out it was £30,000 or less. He was living off her income and accumulating debts. ‘He lives in a fantasy world where he is the affluent Action Man, admired by one and all,’ says Kate.

The women tracked down Tom’s previous wife, as well as two ex-girlfriends. Each left him after a few years, but with enormous difficulty. ‘Last year a friend directed me to a website about narcissistic personality disorder,’ says Leonie. ‘It was as if the light had been switched on. The more I read, the more I realised this was all about Tom. He’s already engaged to another woman. It will be her turn next.

How narcissistic are you?

If a person displays five or more of the following traits, they are likely to have narcissistic tendencies

A grandiose sense of self-importance (eg, exaggerates achievements and talents, expects to be recognised 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, ie, unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations

Is interpersonally exploitative, ie, takes advantage of others to achieve his or her own ends

Lacks empathy: is unwilling to recognise 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 behaviours or attitudes

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