Dr Dimaggio is Psychiatrist and Psycotherapist at the Center for Metacognitive Interpersonal Therapy in Rome.
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.
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’ successs.
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
colleagues
9 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.
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.
CASE VIGNETTE
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).
Conclusions
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?
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