Despite its survival and final inclusion in DSM-5, narcissistic personality disorder remains a controversial diagnosis. With a lifetime prevalence of 6.2%, it is less frequently identified in psychiatric settings but more often seen in private practice and applied to higher-functioning patients.1,2 Conceptualizations and diagnostic definitions of narcissistic personality disorder have primarily focused on the more strikingly provocative, self-enhancing, entitled interpersonal behaviors and attitudes that tend to capture the attention of clinicians rather than on the patient’s underlying, internal struggles. This has contributed to making the diagnosis more judgmental rather than informative.
Advances in understanding narcissism
One of the major advances in recent clinical and empirical studies of narcissistic personality disorder is the recognition of co-occurring vulnerability (eg, insecurity, inferiority, fragility) that accompanies emotion dysregulation.3 Similarly, the proposed hybrid model for personality disorders in DSM-5, which includes both dimensions and central traits, incorporates evaluations of level of functioning, as well as of sense of identity, fluctuations in self- and self-esteem regulation, and empathic capability.
Research in social and personality psychology has added significantly to our general understanding of narcissism. Nevertheless, research on narcissistic psychopathology is still sparse, mainly because of low societal urgency and health costs. Signs of narcissistic personality disorder are often more noticeable within organizational, social, family, and legal or forensic settings. Patients with this personality tend to seek treatment when they are facing serious ultimatums, failures, losses, or other consequential realizations. When in treatment, they are known for their reluctance, negative therapeutic reactions, and early dropout.
Narcissistic personality disorder is often comorbid with other psychiatric disorders for which treatment is sought. However, when such conditions are present, especially substance use disorder, bipolar disorder, eating disorder, or MDD, the clinical indications of pathological narcissism in the initial psychiatric evaluation and treatment planning are likely to be less noticeable or ignored. The underlying contribution of narcissistic personality functioning to a psychiatric disorder may be totally unrecognized; this prevents remission and contributes to relapses and refusal to follow psychiatric treatment recommendations.
The nature of narcissism and its application to psychopathology
Narcissism ranges from healthy and normal to pathological and severely malignant. It is closely related to regulation of self-esteem and emotions and to a sense of control and competence. Narcissism can be a motivating factor and can contribute to exceptional and remarkable accomplishments in higher-functioning people, even when it co-occurs with pathological narcissistic traits and dimensions. It is important to recognize not only the range of pathological narcissistic functioning (ie, self-enhanced/grandiose and vulnerable/insecure), but also the areas or context of the patient’s sense of agency with competence and abilities.
When treating a patient with narcissistic personality disorder, clinicians tend to assume that competence, self-esteem, and positive interpersonal interactions are deceptive “cover-ups” or “defenses” against more severe narcissistic traits, vulnerability, or the “true self.” The patient’s mistrust, negative reactivity, and treatment discontinuation are often caused by such inferences made early in treatment. An alternative clinical approach, both in evaluation and treatment, is to encourage and collaboratively explore the patient’s own accounts of problems and experiences—and especially of fluctuations in functioning, self-esteem, identity, and interpersonal interactions. The aim is to establish a shared agreement regarding the patient’s narcissistic psychopathology and its interaction with self-esteem and interpersonal functioning.
CASE VIGNETTE 1
Mr S, an engineer in a high-tech company, describes his struggle with insecurity in certain interpersonal interactions and social contexts, especially when they involve upper management and competitive colleagues. In these situations, he begins to shake, lose cognitive flexibility, and is unable to access words and expressions. He has been struggling with this since elementary school when he had teachers who scolded him when he could not correctly answer questions, and his parents had forcefully demanded that he “suck it up” and do his best.
Mr S is perceived by his peers, friends, and family as a high-achieving, stoic, critical, demanding man who can easily make others feel insecure or even resentful. Mr S was forced to seek treatment because of his increasing alcohol abuse, which was discovered by his colleagues and immediate supervisor. For many years he had engaged in hidden, controlled but gradually increasing alcohol consumption to manage stress, insecurity, and even fear in interpersonal interactions, both at work and with his wife and son.
This vignette highlights a multifaceted interactional pattern between narcissistic personality functioning and substance use disorder, competence and fragility, internal vulnerability and external self-enhancement. Obviously, Mr S’s substance use served the function of regulating insecurity and numbing intense reactions and emotions, especially in interpersonal contexts. The aim in treatment is to engage and balance Mr S’s abilities and self-esteem, which are related to his competence and commitment, with a gradual processing of his experiences of insecurity, loss of competence, and vulnerability.
Attachment patterns in narcissistic personality disorder
Pathological narcissism and narcissistic personality disorder primarily include avoidant, preoccupied, dismissive, and “cannot classify” interactive patterns.4 The intense preoccupation of patients with negativity, blame, and criticism, as well as their engagement in a range of strategies to manipulate, avoid, and dismiss both the clinician and certain people or contexts in their lives can contribute to stalemates, misguided interpretations, and negative enactment.
CASE VIGNETTE 2
Ms G, an intelligent woman in her mid-20s, is an inpatient in an eating disorder program. Many of the sessions with her psychotherapist are spent complaining about program conditions and the way staff and other patients treat her and making various demands (eg, need for individual attention, different treatment modalities). She also feels that the other patients get away with inappropriate behavior without consequences. When her treatment team accedes to her requests, she dismisses them and always finds faults, misguided intentions, or unacceptable conditions. She perceives efforts to help her as being detrimental to her well-being.
She feels increasingly detached and isolated in the program and begins to express sadness and crying in addition to anger and complaints. The therapist attends to her negativity. Ms G is encouraged to explore past interpersonal experiences and to talk about her sadness. She begins to give more coherent descriptions of her mother’s early death and subsequently growing up with her father. She describes numerous subtle but nevertheless challenging experiences, such as her father’s inattention alternating with intense critical responses to her behavior as well as his involvement with different girlfriends that left her feeling overpowered, unseen, and nonexistent.
Her severe eating disorder became a way for Ms G to regulate anger, to take control and gain power, and to invest in her own identity and desired self-image. Once she was able to access her underlying sadness and describe her deeply rooted and previously nonverbalized emotional experiences, she became more actively involved in her treatment. She began to eat and started engaging with some of the other patients, and she began to outline goals for her future.
This vignette demonstrates attachment patterns that can unfold and dominate the therapeutic alliance during the treatment of a patient with a co-occurring eating disorder and pathological narcissism/narcissistic personality disorder. The systematic exploration of underlying experiences and psychological trauma that contribute to reactivity and self-enhancement, as well as to dismissive, avoidant, and preoccupied interactive patterns, can alter narcissistic functioning.
Recent studies especially in the field of neuroscience have contributed to significant reconceptualization of empathy.5 Identified in terms of ability to understand, process, and share the emotional state and experiences of others, empathic engagement depends on both emotional contagion and cognitive theory of mind, as well as on self-regulatory processes (emotions and self-esteem), motivation, and social interpersonal skills and decisions. DSM-5 conceptualizes empathy as a dimension of personality functioning related to comprehension and appreciation of the experiences and motivations of others, tolerance of differing perspectives, and understanding of the effects of one’s behavior on others.
Clinically defined, empathy is not static; it fluctuates and is affected by a range of contextual as well as emotional, interpersonal, and neuropsychological functions. Studies have found empathic ability in narcissistic personality disorder to be compromised and fluctuating, influenced by the interaction between deficits, capabilities, and motivation.6 More specifically, patients with narcissistic personality disorder have intact cognitive empathic ability and can identify with thoughts, feelings, and intentions of others. However, their capacity for emotional empathy is compromised, especially their ability to care about and share feelings of others.
CASE VIGNETTE 3
Ms F, a professional woman and single mother of an 8-year-old son, describes a very emotional situation at work. The young daughter of one of her colleagues had lost her battle with cancer. Everyone in the department was emotionally affected by this tragic event and engaged in various ways to console their grieving colleague. Ms F described the situation as unbearable. She was noticeably upset and frustrated as she complained about the emotional reactions of her colleagues—she felt overwhelmed and had to leave the office.
Ms F also thought that this emotional outpouring was interfering with work and misdirected attention from an important project with a looming deadline that she was in charge of. From her perspective, successfully meeting the deadline was crucial for her upcoming promotion.
The therapist begins by validating Ms F’s challenges and viewpoint and encourages her to further describe her experiences. Ms F shifts mood and perspective and says, “Don’t take me wrong, I realize that my colleague has suffered a terrible loss, and I feel for her. I signed the condolence card and donated money, but I can’t stand all these feelings—I can’t hug her and let her cry on my shoulder the way everyone else is doing.” After a moment of silence and further consideration, Ms F says, “This whole situation reminds me of when my sister suddenly died when I was 8 years old. It was a terrible event, especially for my mother, and I was told to be strong and not show any feelings. I am also afraid of losing my son . . . this whole event just became too personal.”
This vignette clarifies a range of empathic functioning, especially with regards to emotion regulation. The patient’s initial self-enhancement with immediate concerns about her own position and intense negative dismissive reactions toward her colleagues gradually tapered down as her ability for cognitive empathic understanding and concern unfolded. Furthermore, her experiences of loss and accompanying family reactions, as well as her fear of facing a similar loss, interfered with her processing of the present event.
Perspectives on treatment and prognosis
The major shift in treatment of narcissistic personality disorder occurred in the 1960s with the pioneering contributions of Heinz Kohut and Otto Kernberg, who both claimed, although with radically different approaches, that narcissistic personality disorder was treatable with psychoanalytic psychotherapy. Since then, additional treatment modalities have focused on narcissistic personality disorder—in particular transference-focused, metacognitive, and schema-focused therapies.7-9
Comorbid conditions such as mood, anxiety, and impulsivity can be treated with psychopharmacology, but there are no psychotropic medications indicated for narcissistic personality disorder. Recent research on emotion processing and regulation has contributed to our understanding of the complex interaction between narcissistic hypersensitivity and reactivity—often hidden but serving as underpinnings for more overt self-enhancing, dismissive, or avoidant interpersonal patterns.10-13
Collaborative exploratory strategies that focus on identifying and unfolding these very individual patterns need to be considered when making treatment decisions. Alliance building and engaging the patient’s sense of agency and reflective ability are essential for change in pathological narcissism. The prognosis for narcissistic personality disorder is relative to the diagnostic definition in terms of traits versus dimensions. A recent study found a 2-year remission rate of 52.5% but high dimensional stability.14 This finding suggests both short-term context-dependent as well as long-term enduring patterns of narcissistic personality disorder. Differentiating these patterns and identifying and applying suitable and optimal treatment strategies are still works in progress.
Dr Ronningstam is Associate Professor (PT) at Harvard Medical School in Boston and Clinical Psychologist at McLean Hospital in Belmont, MA. She reports no conflicts of interest concerning the subject matter of this article.
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