Oxford Textbook of Psychopathology
Chapter 30
Narcissistic personality disorder and pathological narcissism

DMS Narcissistic personality disorder: Pathological narcissism as extreme grandiosity

The DSM-5 NPD diagnosis exemplifies the conceptualization of pathological narcissism as excessive grandiosity.

Criteria for NPD in DSM-5

The DSM-5 criteria for NPD describe the following symptoms: 1) the person with NPD has an inflated sense of self-worth 2) is preoccupied with fantasies of unlimited influence, achievement, intelligence, attractiveness, or romance 3) believes that he or she is extraordinary or distinctive and can only be understood by, and should only associate with, other unusual or elite status people or institutions 4) requires excessive respect, appreciation and praise 5) has a sense of privilege and due 6) is willing to use and take advantage of others for personal gain 7) lacks compassion 8) is often jealous of others or believes that others are jealous of him or her 9) exhibits conceited, self-aggrandizing behaviours and attitudes.

The diagnosis reflects chronic expression of excessive or extreme grandiosity.

Prevalence

It is the least commonly diagnosed PD. Prevalence of NPD ranges from 0-5.7%.

Stability

The temporal stability of NPD is modest.

Discriminant validity of NPD criteria

The discriminant validity of NPD against other PD’s is poor.

Comorbidity

NPD exhibits the highest rates of comorbidity with antisocial and histrionic PDs. There are also comorbidities with symptom disorders. Diagnoses that most strongly predicted comorbid NPD are: bipolar I disorder, anxiety disorders, drug dependence, post-traumatic stress disorder, mood disorders and substance use disorders.

NPD research

Research on NPD is rare because of the low prevalence.

Patients with NPD exhibit deficits in emotional empathy but not cognitive empathy.

Patients with NPD have smaller gray volume in the left anterior insula and in frontoparalimic brain regions comprising the rostral and median cingulate cortex and the dorsolateral and medial parts of the prefrontal cortex.

Patients with NPD show a specific deficit for emotions representing fear and disgust. They do not have lower explicit self-esteem.

There are no empirically validated treatments for NPD.

Critiques for NPD

The lack of research on patients with NPD renders the validity and clinical utility of the diagnosis questionable.

The low prevalence of NPD reported in large-scale epidemiological studies are lower than the rates being treated in psychotherapy. It may be that there is a lack of sufficient NPD criteria.

Clinical theory and research: pathological narcissism as grandiosity and vulnerability

Clinical theory and observation have included states of negative affectivity, fragile and contingent self-esteem and behavioural dysregulation in the portrait of pathological narcissism.

Object relations and self psychology

Object relations theories recognize that humans are social beings who experience much of life relating to others. These theories emphasize the importance of understanding how people’s mental representations of self and others positively or negatively impact their identity, emotions and relationships.

Early in development, a child is unable to attribute good and bad experiences to the same person, so he experiences the other as ‘all bad’ or ‘all good’. The self is experienced as ‘all good’ and any information to the contrary is pushed out of awareness (denial) or located in another person (projection). Over time, the child learns to integrate good and bad experiences into a complex and integrated view of self and others.

According to Kerbegr, parental figures (some of the earliest ‘objects’ one can relate to) are experienced as cold and harsh, and they may concurrently hold high (yet superficial) expectations for their child in hopes of vicarious fulfilment of their own failed ambition. These conditions lead to good and bad experiences remaining un-integrated in the form of idealized and devalued views of self and others. The narcissistic individual libidinally invests in a distorted self-structure, based on immature real and ideal self-representations, as well as ideal object-representations. Devalued or aggressively determined self- and object-representations are split off or projected. A pathological grandiose self is constructed by combining all of the positive and idealized characteristics of the self and others, leading to an unrealistic self-image that is hard to maintain.

Kohut defined narcissism as a normal stage of development. A primary narcissistic structure fist exists where the self and other are both idealized. Through receipt of healthy support and empathic mirroring form parental figures, this structure is reinforced and leads the child to experience the world as secure and consistent. Parents will occasionally not support the child needs, but this is tolerable and allows the child an opportunity to regulate their own needs. These experiences coalesce into a new healthier self-structure that his better equipped to navigate disappointments. This transforms immature grandiosity into realistic ambition. Narcissistic pathology arises when parental figures do not provide appropriate support or mirroring, or when parental support is excessive.

A contemporary clinical model

This model conceptualizes pathological narcissism as a combination of maladaptive self-enhancement motivation (grandiosity) and impaired self- and emotion regulation in response to self-enhancement failures and lack of recognition and admiration from others (vulnerability).

Self-enhancement and regulation

Narcissism can be defined as an individual’s tendency to employ a variety of self-regulation, affect-regulation and interpersonal processes in order to maintain a relatively positive self-image. This involves: 1) needs for recognition and admiration 2) motivations to overtly and covertly seek out self-enhancement experiences from the social environment 3) strategies to satisfy these needs and motives 4) abilities to manage disappointments and self-enhancement failures.

Such needs and motives become pathological when they are extreme and coupled with impaired regulatory capacities.

Pathological narcissism involves impairment in the ability to regulate the self, emotions and behaviour in seeking to satisfy needs for recognition and admiration. Narcissistic individuals have difficulties transforming narcissistic needs and impulses into mature and socially appropriate ambitions and conduct.

Early empathic failures by parental figures leave the child ill-equipped to regulate the self, and instead self-regulation is played out in the social arena. The early negative parenting also leaves the self with a mistrust and disdain for others. Other people are needed for he narcissist to self-enhance, but the devalued and sceptical view of others limits the narcissist’s ability to experience others’ admiration, praise, and validation as self-enhancing. This leads to lingering self-doubt and vulnerability, leading to continuing seeking self-enhancing experiences in maladaptive ways and inappropriate contexts.

The fundamental dysfunction in pathological narcissism involves chronically unsatisfied needs for recognition and admiration that lead to an equally chronic preoccupation with the social status of the self and prioritization of self-enhancement motivation. This heightens the individual’s sensitivity to ups and downs and impairs their regulation of self-esteem, emotion, and behaviour.

Narcissistic grandiosity and vulnerability

Narcissistic grandiosity is maladaptive self-enhancement. Narcissistic vulnerability is self, emotional, and behavioural dysregulation in response to ego threats or self-enhancement failures.

Subtypes of narcissistic personality disorder are: 1) the arrogant narcissist, copes with self-esteem dysregulation by creating an exaggerated sense of superiority and uniqueness as well as by engaging in grandiose fantasies. They exhibit entitlement, exploitativeness, and lack of empathy. They experience intense envy and aggression as a result of their affect dysregulation 2) psychopathic narcissist, copes with self-esteem dysregulation by engaging in antisocial behaviours to protect or enhance their inflated self-image 3) shy narcissist, deals with self-esteem dysregulation by engaging in grandiose fantasy while also feeling intense shame regarding their needs and ambition. They avoid interpersonal relationships because of hypersensitivity to ego threats and self-enhancement failures.

The psychodynamic diagnostic manual subdivided narcissistic personality disturbance into subtypes: 1) arrogant/entitled, grandiose. Characterized by seething anger, manipulativeness, pursuit of interpersonal power and control, lack of remorse, exaggerated self-importance, and feelings of privilege. THey tend to be externalizing and have little insight into their behaviour. 2) depressed/ depleted, vulnerable. Fails to maintain a grandiose sense of self such that when their defences fail, narcissistic injury evokes shame, anxiety, depression and feelings of inadequacy.

Clinically important associated features of NPD and pathological narcissism

Suicidality

Pathological narcissism and NPD are risk factors for suicidal ideation and behaviour. Presence of comorbid depression may accrue a greater risk. Experiencing difficult life stressors increases suicide risk.

Increased suicide risk is related to both narcissistic grandiosity and vulnerability. The frequency of parasuicidal behaviours is predicted by narcissistic vulnerability.

Grandiosity may catalyse suicidality by promoting a view of the self as indestructible, a preoccupation with one’s physical appearance, and a detachment from one’s emotional and physical self. Suicide may function as a means of complying with fantasies of invincibility or eliminating imperfections in the body. It may serve an aggressive function to punish others or to bolster an illusion of control over one’s life and relationships with others.

Vulnerability may catalyse suicidality by promoting the experience of narcissistic injury, leading to the deflation of grandiose self-views and the experience of shame in recognizing imperfections, personal weaknesses and defeat. It may serve a function to punish the self.

Depressive experiences

The phenomenology of depression in narcissistic patients may vary. Analytic/dependent themes of depression are associated with grandiosity. Introjective/self-critical themes are associated with vulnerability.

Self-criticism and perfectionism in depressed patients may involve deeper narcissistic issues.

Narcissistic individuals may be susceptible to depression because their self-worth is dependent on external affirmations from the social world, and their psychic cohesion can become threatened if these needs are not met.

Aggression

Grandiose children are more aggressive, reactive as well as proactive.

Vulnerability predicts aggressive feelings, but not aggressive acts.