Psychiatric Times. Vol. 29 No.

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CLINICAL

Narcissistic Personality Disorder:

Rethinking What We Know
By Giancarlo Dimaggio, MD | July 18, 2012
Dr Dimaggio is Psychiatrist and Psychotherapist at the Center for Metacognitive Interpersonal
Therapy in Rome.

Surprisingly, to the eyes of many experts, the draft of 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 co‐morbid
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 hyper‐valued to self‐derogation along with fluctuations in self‐esteem.
This is consistent with the idea that nuclear narcissistic states are not limited 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’ success.

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

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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 succinctly 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.

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Agency and goal‐setting

The early observation by Kohut3 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

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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 over‐controlling 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

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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).

TABLE

Psychotherapy tips for working with persons with narcissistic personality disorder

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?

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 • 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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