​Pathological narcissism is believed to develop in response to early traumatic empathic failures by caregivers who were experienced as confusing, unpredictable, and full of hidden agendas. Inconsistent and untrustworthy caregiving creates a sense of insecurity and instability in a child’s sense of self, resulting in fragile self-esteem that becomes heavily reliant on external affirmation. To manage their deep-seated need for admiration and intense yearnings for approval, the child learns to present a false self, masking true feelings and vulnerabilities that have been unrecognized or unacceptable to caregivers, while instilling a fear of exposure and consequent criticism and rejection. The affective experience of not being seen or known by caregivers during critical developmental periods alters a child's sense of self, affecting their self-worth and agency and impairing their ability to form secure attachments, as they divest themselves of meaningful emotional investment in others.

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These difficulties in regulating self-esteem can result in pathological narcissism, a disorder characterized by dynamically oscillating states of grandiosity and vulnerability. Narcissistic vulnerability manifests as a brittle sense of self, emotional instability, and impaired empathic functioning, coupled with excruciating feelings of shame, self-doubt, rage, envy, and loneliness. In response to these vulnerabilities, individuals employ maladaptive, self-enhancing strategies to bolster a view of themselves as exceptional and deflect recognition of their vulnerabilities. Expressions of narcissistic grandiosity often impede meaningful relationships, including the capacity for mutuality and reciprocity.

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The impact of untreated pathological narcissism on partners, family members, and children is significant. Through the projection of their intolerable feelings of inadequacy onto others, narcissists perpetuate cycles of intergenerational trauma and cause devastating social effects. This has led to a greater awareness of the need for mental health support and treatment for those affected by individuals with pathological narcissism. Treatment is usually sought only after an acute personal or professional failure, loss, or crisis (e.g., excessive interpersonal conflict with family and/or employers, increasing dissatisfaction with one’s life, etc.). The mainstay of treatment is individual psychotherapy—specifically, psychoanalytic treatment—which is typically long-term in nature.