Well, hello, little prancing
dear lol - I mean, deer

I agree with you that medication can't cure NPD... because it's not a physiological disease or a chemical imbalance, imo.
And I can picture N being "honest" (I can't even use that word with regard to N unless I put it into quotes... sheesh) in therapy - - - right up to the point where he's asked to look within to locate the source of his misery. That's where he'd get stumped, imo.
But you know... my ex's mother was quite a case, in her younger years...
just exactly the sort that you'd imagine might spawn a N...
but she was not a bit N herself, imo, when I met her in her 70's.
In fact, I believe that she recognized exactly what her son had become and felt deeply saddened by that knowledge. He lived with her before we married, and nearly drove her mad with his shenanigans. But that's beside the point, sorry. It's just that you woulda sworn she was N herself, by the way her earlier life was described by other family members... and yet I couldn't see a speck of it in her later. So I cannot let loose of the notion that people can change, if they're willing to.
I think your view gives too much weight to nurture over nature... but that's because I don't think that babies are born blank slates. Each of my children had a very definite and distinguished personality from birth... and each has responded differently to her/his life circumstances to date (many of which have been far from pleasant).
This fits with what I experienced of NPD-ex:
He builds a fantasy life for himself, and as he ages, he mimics the people around him, but actually has no personality of his own. He trusts no one, but he must be the best considering everybody hated him.
That's a common theme I've seen with NPD. They have no personality of their own and trust no one, yet try to assume the personalities of others they envy,
along with name-dropping about supposedly important people with whom they've associated.
But I don't believe that he needed
ALL those people in the first years of his life to come forward and admit their failure to see to his needs in an emotionally healthy way.
He was able to express his needs to me, on occasion... so there was, at some level, an awareness of them.
Trouble was, no sooner did he express them than he'd punish me in some way, because now I knew his secret. He was vulnerable... and it was that vulnerability that he hated.
I understand that the N's you knew seem to have had very difficult lives... but I don't think that's always the case. Just thinking that... over-coddling and overly "spoiling" a child is said to be another potential way of winding up with N. So it's not just about feeling empty inside and not having received adequate care. It's a choice, I think still... always a choice...
and a very prideful one... to worship one's image of one's self above all.
Izzy, what did you mean by "a younger sister was born"
for you?
Carolyn