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Narcissistic Personality Disorder: Rethinking What We Know: Page 2 of 3

Narcissistic Personality Disorder: Rethinking What We Know: Page 2 of 3

Table. Psychotherapy tips for working with persons with narcissistic p...

Agency and goal-setting

The early observation by Kohut 3 that persons with NPD lack an inner drive to act was counterintuitive, because at least from the overt, blatantly arrogant type, one would expect a tendency to ruthlessly keep singing “I shall overcome.” But, when persistence is needed, strongly narcissistic persons tend, after some initial sparkling moments, to decline. Clinical experience with such patients highlights the fact that when they are not struggling for grandiosity or fighting against a tyrant, they lack access to those innermost wishes that could make them feel alive and vital and instead feel flat and inanimate. They lack a sense of existential agency. Thus, they are other-directed and their striving for admiration is a coping strategy for avoiding a sense of nothingness.

DSM-5 observations such as “excessive reference to others for self-definition” or “goal-setting is based on gaining approval from others” capture this agency deficit—a problem that is a primary psychotherapeutic target. Overall, agency in narcissism is 2-sided: when social rank is at stake and narcissists feel competent, they are self-sufficient and feel mastery over the situation, which triggers grandiosity. When there are other motives, such as when success is not in sight, and when narcissists feel vulnerable or in difficulty, agency diminishes. In this latter case, they feel paralyzed, empty, and passive.

Impaired empathy and poor understanding of mental states

Empathy dysfunction is considered central to narcissism, with cognitive empathy considered less diminished than affective empathy.1,10,11 Persons with narcissism are able to understand how someone else feels but cannot respond appropriately. Only recently has empirical evidence appeared in support of an NPD criterion that to date was only based on clinical observations. This evidence provides insight into how diminished empathy works in the mind of such persons. Narcissism is associated with less emotional empathy in laboratory tasks but not in self-reports, which is to be expected: narcissists think they are empathic, when in reality they are not.

Cognitive empathy is unaffected, although lack of motivation may reduce the ability to empathize. A functional MRI study showed that persons high in narcissistic traits displayed decreased activation in the right anterior insula during an empathy task.10 Study participants were unaware of their empathy impairment, which is a typical feature of narcissism and warns against using self-reports for investigating empathy in the NPD population. It is interesting to note that study participants who were high in narcissism and low in empathy were also more unaware of their own emotions. This finding is consistent with claims that reduced empathy is part of a wider impairment in the system of abilities to understand mental states, which includes poor self-awareness.5,12 Indeed, persons with NPD feature an inability to recognize some emotions in the self and, in particular, to understand the triggers for emotional reactions.

DSM-5 ascribes dysfunctions in self-awareness to NPD, “often unaware of own motivations” or noting narcissistic tendencies to be “excessively attuned to others’ reactions but only if perceived as relevant to self.” Poor self-awareness is the underlying problem in NPD. Although narcissists are fully aware of being annoyed by persons who hamper their goals and attack their vacillating self-esteem, they have difficulty in accessing wishes and needs and in understanding what triggers some of their reactions. As a consequence, they constantly need others to understand their wishes and provide validation and support. Therefore, empathy is a costly and risky action for persons with NPD. This is likely to be connected to the inadequate parenting they received during their development, with caregivers who were unable to appropriately recognize, name, and regulate their affects. Such poor parenting is thought to leave narcissistic adults constantly looking for someone to help them recognize what they feel and to support their wishes, which leave them deprived of any possibility of focusing on others’ mental states.

In short, poor self-awareness yields confusion about wishes and puts the person with NPD at risk for being influenced by others. When others display signs of suffering, the narcissist feels these others are distracting attention that rightly be-longs to him or her and the perception of loss increases. Empathy shuts down.


Fred was a brilliant manager in his late 20s who had NPD. He was a perfectionist who was emotionally constricted, was unable to enjoy life, and reacted to any slights and criticisms with frozen anger or by overcontrolling his behavior to prevent any further criticism. His goal was to reach the highest performance level at work and to be recognized by others for his special qualities. To him, social life made sense only in terms of professional achievements. Any attempts at autonomy or acting spontaneously were inhibited because of fear of criticism and rejection. Self-esteem was regulated either by being successful at work or by physical exercise in order to reach perfect harmony in the functioning of his body. He wanted his girlfriend to be perfect and criticized her when she gained weight. His rigid, overcritical attitude and his inability to fully enjoy sexual life strained their relationship.

During therapy, I adopted a validating stance: recognizing and accepting his wishes for autonomy and need to relax instead of striving to be accepted only when he reached the highest standards. I also pointed out that receiving criticism instead of emotional recognition had made him suffer, something I empathized with.

He was offered a job in a major firm in the Netherlands that would have required him to move abroad. His girlfriend was supportive but also sad at the idea of separation. Fred interpreted this as a sort of emotional blackmail and became angry because he felt she was constraining his freedom.

During sessions, associations were made between his current NPD and events that had taken place when he was younger. He was always an excellent student and at the top of his class, but his father was never satisfied and always expected more. In therapy, Fred understood that for his family, not meeting unrelenting moral and performance standards spelled terror and inability to give life meaning. He realized that he took his girlfriend’s reaction to the job offer as another sign that he could not be free to follow his own plans without evoking negative reactions in others. He realized that she was not being tyrannical, but supportive. Empathy for her increased while at the same time he was able to successfully apply for the new job.


To the best of my knowledge, there have been no randomized clinical trials that have looked at treatment for NPD; therefore, the idea that NPD can or cannot be treated relies solely on clinical judgment. Different approaches, both cognitive and psychodynamic, have devised procedures to deal with narcissism, including, among others, relational psychoanalysis, object-relation psychoanalysis, schema-focused therapy, cognitive analytic therapy, and metacognitive interpersonal therapy.3,4,5,6,13,14 Although treatment guidelines have never been formulated, I have distilled tips for treating narcissism using the reported evidence and the DSM-5 prototype as a potentially reliable guide, with no intention, however, of advocating a specific approach (Table).


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