Narcissistic Personality Disorder: Rethinking What We Know
Narcissistic Personality Disorder: Rethinking What We Know
Surprisingly, to the eyes of many experts, DSM-5 better captures the essence of narcissistic personality disorder (NPD) than previous versions did. Many clinicians (myself included) were dissatisfied with the descriptions of NPD in earlier versions of DSM. Persons with NPD are aggressive and boastful, overrate their performance, and blame others for their setbacks; current editions of DSM portray them as arrogant, entitled, exploitative, embedded in fantasies of grandeur, self-centered, and charming but emotionally unavailable. This portrayal of persons with NPD conveys only a minimal sense of their self-experience and misses their complexity.
Prototypical persons with NPD present with many interpersonal problems and comorbid disorders, such as depression and bipolar disorder, with consequent increases in risk of suicide, alcohol and substance abuse, and eating disorders.1,2 Romantic relationships are typically shallow, and narcissistic persons build and maintain them with difficulty. Conflicts at work are the rule rather than the exception, as are problems with commitment when faced with negative feedback. As these persons get older, mood disorders can worsen because of dissatisfaction with their personal and professional lives.1
Characteristics of NPD
The draft of DSM-5 gives hints of what persons with NPD experience and, most importantly, provides a snapshot of a complex set of their self-experiences and disturbed mental processes. This description, though it may not be complete, is consistent with much of what we know from clinical experience and personality research about both NPD and narcissistic traits in the general population. An inherent problem of NPD is a disturbed internalized representation of self and others.
Self-states and self-other schemas
Feelings of grandiosity and fantasies of power and success are certainly important but are not the core theme in a narcissistic stream of consciousness. The DSM-5 prototype notes how self-appraisal can swing from hypervalued to self-derogation along with fluctuations in self-esteem. This is consistent with the idea that nuclear narcissistic states are not lim-ited to “being the one who sets people’s standards for the year to come,” as the disdainful protagonist of The Devil Wears Prada loved to say.
NPD manifests as anger triggered by feelings of social rejection and tendencies to derogate those who give negative feedback. Persons with NPD often feel hampered in pursuing goals and blame others for being inept, incompetent, or hostile. States in which the self-image is extremely negative are important but are so hard to bear that fighting with others and blaming them for any personal flaws is a more suitable defensive maneuver. When shortcomings are impossible to deny (eg, being fired from work, breaking affective bonds), persons with NPD are likely to become depressed; as they age, the risk of suicide increases. Following the lead of the psychoanalysts Kohut 3 and Modell,4 states of emptiness, emotional numbing, and devitalization are now included in NPD models. Such states are quintessential to the disorder, but they are not included in the current DSM-5 prototype and have been overlooked by researchers. Other prominent narcissistic states include an inability to forgive and feelings of shame, guilt, and envy at others’ successes.
In persons with NPD, self-experience patterns coalesce into self-other relational schemas: the dominant motives are concerns with social rank/antagonism, and the need to be admired and recognized by others as being special; the dominant image is of an “other” person unwilling to provide attention. The main schema is the “self” who desires to be recognized or admired and the “other” who is dominant and critical. In one schema, the self reacts with overt antagonism or by resorting to a metaphorical ivory tower.5 Another prominent schema is the self that needs attention while the other rejects and again criticizes the self, which, in turn, steers the self to compulsive self-soothing and denial of attachment needs.5,6 In general, such persons spend much time ruminating about issues of antagonism/social rank and avoid forming or thinking about attachments, thus concealing their vulnerable self. Empirical support has been found for the possibility that patients with NPD or narcissistic traits tend to seek self-enhancement, to overreact when they perceive others are setting limits, and to self-soothe.7
The development of NPD
There is no consensus on the causes of NPD, although lack of parental empathy toward a child’s developmental needs may bear some responsibility. In the context of disturbed attachment, parents may fail to appropriately recognize, name, and regulate the child’s emotions, particularly in cases of heightened arousal.8 The developing child is therefore left with intense affects that receive no appropriate recognition or appropriate responses, which leads to affect dysregulation. In children, with their basic needs unmet, attachment becomes an issue; this translates to being attachment-avoidant in adulthood yet, at the same time, constantly striving for attention and admiration.
Another trigger for NPD may be that the child is raised in a family where status and success are of utmost importance and only qualities that lead to sustaining a grandiose self-image are valued while other behaviors are disregarded or punished. Another possibility is that overt grandiosity is a reaction to slights and humiliation, a sort of armor used to avoid subjugation.
Other factors, such as an externalizing personality and the role of culture (the narcissistic society) in paving the way to narcissism, should also be explored. Although studies on causation are scant, Tracy and colleagues9 summarize some recent findings in which parenting styles, such as mixtures of overt praise and coldness, lack of supervision, corporal punishment, and authoritarian parenting, predicted future narcissism.
What is already known about narcissistic personality disorder?
? Narcissistic personality disorder (NPD) is characterized by complex self-experiences, including grandiosity, anger, self-derogation, and emptiness or apathy. Lack of empathy is a feature of the disorder. Frequently, there are impaired romantic and professional outcomes as well as co-occurring disorders.
What new information does this article provide?
? Impaired ability to recognize inner states is a feature of the disorder. Evidence for affective but not cognitive empathy is presented. An agency deficit is a core characteristic of the disorder, with typical oscillations between diminished agency and hyperagentic behavior. Structured options for psychotherapy are succintly offered.
What are the implications for psychiatric practice?
? Persons with NPD are amenable to treatment. Understanding that underlying feelings of vulnerability, impaired self-reflection, and diminished agency are core features of the disorder may lead to refined psychological treatments, keep these persons in therapy longer, and promote structural personality change. The need for testing the effectiveness of manualized treatments for NPD is called for.
Regulatory processes
NPD features unrelenting standards for maintaining a sense of self-worth and personal goals valuable enough to be pursued. As a result, narcissism seems to include perfectionism as a trait and, after any accomplishment, the target is usually raised even higher, which results in never-ending dissatisfaction.5 Perfectionist standards are also set for others, which leads the narcissist to easily derogate others for not living up to his expectations. Other strategies for affect and interpersonal regulation are blaming others, withdrawing from relationships, adopting controlling and domineering strategies when facing problems and conflicts, and typically self-enhancing when facing others’ expected feedback.
Dear Guillermo,
thank for your kind comment. In my clinical experience not the majority of patients with NPD have been treated like gods by their parents. If that happened it was usually coupled with harsh criticism about anything the child did unconsistent with grandiose expectations. Instead, many patients of mine report histories of parents that were unreliable, cold, distant, punitive or in some cases with severe mental illness (e.g. paranoia, alcohol abuse). Sometimes it is about a mixture of setting high standards for the children and being unavailable on the other hand or not able to offer support and trust in the children deeds.
best wishes,
Giancarlo
Can narcissistic dedvelop strong attachment with a partner who constantly admire him(her)and actualy acts alike a mirror to his inflated image? my question is based on a personal experience noticing a narcissistic intelligent-educated man,s happy relationship with a simple-unsophisticated wife who constantly admire him and put him in pedestal.
Sorry.I have another question.It is about the DSM V,s description on Narcissism: I have some question about
level of narcissist,s lack of achievement.If it is true,what about the VERY SUCCESSFUL BUSINESS MEN,
POLITICIANS,or PROFESSIONAL people among whom we can find many narcissist particularly CEOs and
Politicians.!!!!.
Posted by susan kweskin | August 31, 2012 1:30 PM EDT
Dr. Ivo Aben, MD, PhD comments:
The description of the characteristics of narcistic personality disorder (NPD) has several similarities with those of Asperger's syndrome. A lack of empathy, of feelings of guilt and regret, and of the capacity to maintain intimate relationships and/or productive cooperative bonds with colleages are examples of those similarities. Both patient groups are vulnerable to comorbid disorders such as depression, substance abuse, and eating disorders. Both disorders can be regarded as developmental disorders as they start to manifest in childhood and interfere with one's overall psychological maturation process. The differences may be more difficult to discriminate. Indeed, Asperger's is regarded as an autism spectrum disorder with a genetic and neurodevelopmentary etiology, while NPD is seen as a pathological development of the self during the first years of life. During childhood, the recognition of specific features of Asperger's syndrome can be relatively easy if the child shows clear symptoms of inadequate contact (absence of eye contact, lack of reciprocity, lack of interest in playing with peers, etc) and stereotypical behavior or interests (behavioral rigidity, inability to cope with deviations from the normal routine, obsessive occupation with some toy or theme). In adulthood, these specific features may have faded and the patient may have learned how to mask some of his inabilities. The differentiation between Asperger's and NPD may be difficult as a result. To me, this seems to be of clinical importance, in the first place because there are different therapeutic options for both disorders. The psychotherapeutic possibilities for NPD mentioned in your article may not be effective in Asperger's patients.
I would be happy to see what you think of these considerations and what you suggest to improve the differential diagnostic process. Thank you in advance.
With kind regards,
Ivo Aben, C&A-psychiatrist, Mondriaan Mental Health, the Netherlands
NPD may have quite different characteristics than Asperger. For one, guilt is far from being absent in persons with NPD, unless they have comorbid antisocial traits. These persons conceal deep guilt feelings, which often makes impossible leave a happy life because they fear if they are happy or succeed others will suffer because of this (survivor guilt). As a result they react with anger when blamed by others, mostly because of avoiding to fall into unbearable pain. Even most pronounced may be the presence of shame - I don't know if such a feeling is present in Asperger, but I guess that as in any form of autism the emotional experience is constricted -.
Then NPD persons may largely differ from one another; while some may resemble to the Asperger profile (again, maybe the ones with antisocial features), others are better functioning. This can be easily seen during succesfull psychotherapies: after having realized others have less power in hampering their goals, and after having them made less reliant on the judgement of others and less sensitive to slights and criticism, they are more cooperative and sometimes display excellent theory of mind skills (which Asperger does not possess as far as I understand the disorder). During therapy many patients of mine and the colleagues I supervise become excellent parent, with fully-fledged abilities to understand their children, play with them and take care of them.
Then the patients with forms of NPD more resembling to the fragile/covert type, fall closer to Avoidant Personality Disorder than Asperger. They constantly seek for admiration but feel criticized and as a result avoid contact, but not because they are not interested, just because it hurts too much.
In sum, I acknoweldge that some with NPD may resemble the Asperger profile and in that case it may well be that two different diagnostic lables are used for describing the same personality: those persons are mostly characterized by severe difficulties in understanding the mind of the others and attune with them, even after therapists' struggles to make them feel validated and understood.
The majority of NPD patients instead display quite a different profile, with a wide array of capacities for relationship and social contact still intact.
Dear Shirin,
1) NPD patients do not avoid relationships, and they do form attachment bonds. It is simply that the attachment pattern they endorse is one of denying attachment! They derogate feelings of closeness and tenderness and often are spiteful toward their partners, but they depend on the (stable) presence of the other. That said, the admiring/admired pattern you describe is likely to exist but... don't trust what you see. You should spend time in the house of this couple and see what happens when the camera is off. Moreover, the admiring/admired pattern usually doesn't last for long. The admiring person starts asking for recognition, and to be cared for, which usually ignites poisonous interpersonal cycles.
2) The super-adapted NPD do exists! Simpy you don't seem them in your consultation room! Also, though they may be labelled as narcissists, it is quite likely they also display antisocial or paranoid features. In any case, they don't seek for help, unless for related problems (e.g. drug-dependence or severe mood disorders). Then, the large majority of persons with NPD lead lives below their capacities, because NPD related features, as inability to bear frustration of sustaing cooperative bonds make their work functioning poor.
I wonder if there is evidence to support a genetic component in the disorder. The debate of nature vs. nurture could be made, but when you see this in members of a family who weren't raised by the same parents, it does make you wonder. Married to a classic NPD for 3 years and can tell you your discussion is one of the best descriptions of the complexities of the disorder I've ever read. Thank you for bringing NPD out of the closet and into the discussion!
Dear Beth,
thank for your very kind words. Congratulations for having survived to such a marriage ;)
As regard genetic, there is no consistent evidence for a heritable component in NPD, some studies say there is some basis, others say that is doubtful. To the best of my knowledge no genetic marker for narcissism have been identified. Things may become even more complex in the future, because the DSM 5 prototype includes the covert (hypersensitive) narcissism, which may feature a different temperament than the overt (grandiose) type, thus yeilding correlations with a different pattern of underlying traits. That said, my opinion is that parenting and culture make a difference, and narcissism is likely either a direct mirror of parental and cultural expectations, or a reaction to poor parenting, with the caregivers unable to provide empathy, attention, support, example of appropriate (pro)social behavior and respect for the child needs.
Know Narcissistic Personality Disorder up close and personal my mother being a textbook case. She was a horrible mother, and in her mind she was perfect and I needed fixing. Her personality had all your standard traits: grandiosity, envious, arrogant. When you get down to it she was downright delusional. And I do believe there is a genetic component as remarked by Beth. My mother's father was exactly the same way. Actually, my mother was probably a combination Narcissistic Personality with Borderline because intense anger was her defining feature and also is the defining feature of BPD (which I'm unlucky to suffer with myself). So yes, from personal experience this is passed on genetically.
Hi,
I am writing from Chile, that means that my English is far from perfetc.
Thank you for your article, only one comment, from my clinical experience many patients with NPD tell a story about being deify during childhood (and even in the present) by his/her parents. Don't you have this experience?
best
gdelap