DSM-5 better captures the essence of narcissistic personality disorder (NPD) than previous versions did. The hypervigilant NPD subtype is the least understood but seen the most often in patients.
Table. Psychotherapy tips for working with persons with narcissistic personality disorder
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.
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.
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).
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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