Research is needed on the hypervigilant NPD subtype, which has been largely understudied in spite of clinicians’ warnings that this is the most frequent presentation in patients. Studies need to focus on the covert/hypervigilant subtype and discover its correlations with symptoms and social functioning. A new and more nuanced description of the narcissistic prototype will generate new case studies, empirical research, and clinical trials. Answering the following questions will help us better understand this problematic personality:
• Will the overt and covert types of narcissism, now lumped together, end up being 2 distinct disorders?
• Are dysfunctions in self-awareness, such as poor understanding of the triggers of an emotion, a feature of NPD?
• Are persons with NPD self-reliant and avoidant of attachment? Do they tend to withdraw when they feel others are accessing their vulnerable self?
• Is it possible to measure problems in goal-directed behavior—ie, impaired agency—and see whether this is a narcissistic feature?
• Will the empathy deficit appear in future studies and the self-report/objective measures inconsistency stay?
• Does the empathy deficit lie at the foundation of narcissism, or is it a consequence of poor self-awareness?
• Are anger at being socially (or privately) rejected and states of numbness, anhedonia, and shutting off the prominent features of NPD?
Dr Dimaggio is Psychiatrist and Psychotherapist at the Center for Metacognitive Interpersonal Therapy in Rome.
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