Narcissistic personality disorder is often equated with the selfie-loving, shallow, boaster that wears on your patience. However, there is significantly more to the condition. Their behavior and mood are often dependent and driven by feedback from their environment; they typically need the message from others to be a positive one. The impression they wish to make and the intense guarding of their fragile self esteem is a strong determinant of their actions and thoughts.
Some narcissists can become stricken with anger, anxiety, depression, shame and so forth if the information they receive does not match their inflated, protected, inner self. From a neuropsychological standpoint, narcissistic personality disorder reflects problems with self and emotion regulation.
People who meet diagnostic criteria can have extremely fragile and fluctuating self esteem. There is a detachment from their true self. The condition often has a negative impact on the lives of people who love or interact with them.
Narcissistic Personality Disorder includes symptoms such as, poor self identity, inability to appreciate others, entitlement, lack of authenticity, need for control, intolerance of the views/ opinions of others, emotional detachment, grandiosity, lack of awareness or concern regarding the impact of their behavior, minimal emotional reciprocity, and a desperate need for the approval and positive attention of others.
Not everyone with pathological narcissism or Narcissistic Personality Disorder will have the same presentation of the condition. There is heterogeneity of course, because people are complex. There are differing levels of intensity and dimensions. For example, some with pathological narcissism are shy and avoidant (vulnerable), while others are primarily outgoing and overtly boastful (grandiose).
Cluster B Personality Disorders
Narcissistic personality disorder falls under the category of Cluster B Personality Disorders within the DSM-5. The conditions under this grouping include Borderline Personality, Narcissistic Personality, Histrionic Personality, and Antisocial Personality. Psychopathy, a condition marked by a lack of conscience, incapacity to bond, aggression, and interpersonal violations, is a subgroup within Antisocial Personality Disorder.
Although the disorders are distinct and reflect different categories of symptoms, it would not be unusual for someone to have symptoms of more than one Cluster B condition. As many psychologists and psychiatrists will attest, the personality profile of our patients does not always fit into a nice little box. There can be traits of other personality disorders that accompany the main condition. Take for example the combination of narcissistic and antisocial personality in describing malignant narcissism.
"I am so smart!" My IQ is above140."
A prominent feature of narcissistic personality disorder, regardless of the dimension (e.g., grandiose, vulnerable, mixed with traits of other conditions), is self enhancement. They view themselves in an overly positive light and believe they are unique and superior to others. In a meta-analysis review, researchers Grijalva and Zhang explored the insight of individuals with narcissistic personality disorder. The studies supported that people high in narcissism tend to over-estimate or exaggerate their abilities, status (e.g., intelligence), and looks, than could be supported by reality.
They believe they are better than other people and usually the variables that are self-enhanced are related to "power and status" (agency). Even if evidence to the contrary is presented, such as the results of an IQ test. Often that reality will be challenged rather than accepted. They might become extremely defensive and verbally attack or degrade the examiner who gave the test or the test itself (e.g., "What a stupid test!") Indisputable evidence of their inaccurate, overly inflated self assessment does not change the self-view of someone high in narcissism.
"Make them believe I'm smart and handsome. I won't stand for anything else!"
In Section III of the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition ("Alternative DSM-5 Model for Personality Disorders"), conditions associated with personality are conceptualized differently from the current diagnostic criteria. Consideration is given to both an individual's "functioning" as well as personality "traits" and are considered along a continuum, with dimensions. As a clinician, I find this approach more in line with the complexity of human behavior.
With regard to Narcissistic Personality Disorder, Section III highlights that people with this condition have "vulnerable self esteem." This is regardless of whether the person is extroverted/introverted or rather of the "vulnerable" or "grandiose" variants. They require regulation from the outside world to maintain many facets of the self. Therefore, they often use people to stabilize their emotions and the feelings they have regarding who they are and what they want to do or be.
Research indicates that individuals diagnosed with narcissistic personality disorder have some of the neurobiological impairments of psychopathy. This makes sense, given that narcissistic personality disorder is suspected to fall along a spectrum that includes psychopathy. One neuroimaging study found those with narcissistic personality disorder to have problems associated with the right anterior insular cortex - a region of the brain suspected to be associated with empathy.
In a 2013 publication, using neuroimaging, researchers from the University of Germany examined the brain patterns of individuals with narcissistic personality disorder. They yielded similar findings to the aforementioned study. The group who met criteria for the condition demonstrated smaller gray matter volume within areas of the brain associated with "emotional empathy" (i.e., anterior insula and the fronto-paralimbic areas).
Neuroscience studies of this nature lend considerable evidence that people with pathological narcissism have limited capacity to interact pro-socially with society. Faulty brain functions are a significant hindrance.
There is more to narcissism than intensity levels. Studies have identified the presence of dimensions. Some researchers refer to them as variants or subtypes, however Dr. Kenneth Levy's 2012 review of the literature suggests it is likely most accurate to view the variants of this condition as dimensions and "dynamic." This reflects the reality of narcissistic personality disorder, whereby an individual can show patterns of more than one variant. The two most commonly described dimensions or variants in research are, grandiose and vulnerable.
• Grandiose: The descriptor often offered for this pattern of narcissism are extroversion, overt attention seeking, and grandiosity.
• Vulnerable: reflects a neurotic style whereby an individual demonstrates a quieter/ introverted presentation, anxiety, mood problems, avoidance, and modesty.
I want to explore with you the darker side of narcissistic personality disorder where aggression, antisocial behaviors, and suspiciousness are as prominent as their poor sense of self, fragility, and egocentricity.
(Below is a clip from a video that explores the symptoms of malignant narcissism.)
A person with malignant narcissism has the potential to destroy families, communities, nations, and work environments. This condition reflects a hybrid or blending of narcissistic and antisocial personality disorders. Psychologist Eric Fromm, PhD termed the disorder in 1964. Psychoanalyst, Otto Kernberg, MD later delineated the symptoms of the condition and presented it as an intermediary between narcissistic and antisocial personality disorders.
Individuals with this profile can form connections with others. However, they process information in ways that can hurt society in general, but also the people who love or depend on them. Family, co-workers, employees, and others in their lives often have to walk on eggshells to appease a fragile ego and minimize the occurrence of their unstable, impulsive, or aggressive behaviors.
They lash out or humiliate others for infractions of even the most frivolous nature (e.g., You gave an opinion that differed from theirs. | You demonstrated confidence and it made them look bad. | You told a joke that involved poking fun at them.)
For some, their grandiosity and protection of their fragile "true self" can be at such extreme levels that they will lie and give the impression that simply because they say it that makes it reality. Many will become angered if their lies are challenged with truth or facts. Of course this can create problems for the people close to them, as this pattern of behavior can easily veer into gaslighting.
Malignant narcissism is a blend of two disorders that pose problems interpersonally for their victims - narcissistic and antisocial personality disorders. It is not uncommon for others to feel anxious, intimidated by, and fearful of people with this condition. The combination of poor empathy, coupled with aggression, hypersensitivity, and suspiciousness can bring pain to others.
Those who interact with malignant narcissists often consider them jealous, petty, thin-skinned, punitive, hateful, cunning, and angry. Given their shallowness, they are not regulated emotionally and have beliefs that swing from one extreme to the next.
Their decisions can hurt others because they rank relationships and people based on superficial standards and categories. They want to land on top, even when pretending to be altruistic or engaging in an activity that should not be 'all about them.' They often view the world through a primitive binary lens (e.g., winner/loser; smart/dumb; rich/poor; pretty/ ugly; black/white) - all the while sustaining the belief they are superior. This is likely associated with problems processing emotional information, which reflects faulty neurobiology.
Researchers Gunderson and Ronningstam reviewed the works of Robert Hare, Ph.D. (creator of the Psychopathy Checklist) and Otto Kernberg, MD (i.e., malignant narcissism). They cited that both individuals found narcissistic personality disorder to be a component of or veer into other conditions that are related, such as antisocial personality disorder and psychopathy.
Both Hare and Kernberg discuss the inclusion of narcissistic personality disorder within more sinister, destructive personality types. Given that it seems there is a high correlation between antisocial and narcissistic personality disorders, Drs. Gunderson and Ronningstam decided to explore whether or not narcissistic personality disorder is truly a condition that is distinct from antisocial personality.
They found that grandiosity was a significant discriminator between antisocial and narcissistic personality. Specifically, individuals with narcissistic personality tended to be “boastful,” arrogant and grandiose regarding their abilities and achievements. Although they determined that both groups (ASPD and NPD) exploit others, exploitation was more apt to be the goal of those with antisocial personality.
Although I presented the viewpoint of a narcissism spectrum, some researchers take the angle of an antisocial spectrum, while others consider each of the Cluster B disorders as overlapping.
I am in agreement with research that conceptualizes personality disorders such as narcissistic personality and antisocial personality as falling along a continuum. Across the continuum or spectrum will be different blends of the disorder, distinct, however, composed of symptoms of each other. I think that the overlap is often significant and the current categorical classifications of personality often leave out blends of personality that we see with our patients (e.g., malignant narcissism, psychopathy with borderline traits, introverted narcissism).
Video Clip from a Malignant Narcissism educational piece:
Rhonda Freeman, PhD, neuropsychologist exploring the neuroscience of healthy and abusive love relationships.
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