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Narcissistic Personality Disorder: A Clinical Perspective ELSA RONNINGSTAM, PhD

Narcissistic traits and narcissistic personality disorder (NPD) present specific diagnostic challenges. While they are often readily and straightforwardly identified, their presentation in some patients and the reasons for which such patients seek treatment may conceal significant narcissistic pathology. Recently, several empirical studies have confirmed that the phenotypic range of people with NPD includes individuals with insecure, shy, and hypersensitive traits with prominent internalized narcissistic features and functioning. Other studies have confirmed that internal emotional distress, interpersonal vulnerability, fear, pain, anxiety, a sense of inadequacy, and depressivity can also co-occur with narcissistic personality functioning. This paper focuses on integrating these findings into the diagnostic evaluation and initial negotiation of treatment for NPD. In patients with narcissistic traits or NPD, it is important to give attention to the two sides of character functioning, which include both selfserving and self-enhancing manifestations as well as hypersensitivity, fluctuations in selfesteem, and internal pain and fragility. This article highlights some of these seemingly incompatible clinical presentations of narcissistic traits and NPD, especially as they co-occur with depressivity and perfectionism, and it discusses implications for building a treatment alliance with a patient with such a predominant disorder of character functioning. The article also discusses the importance of retaining the NPD diagnosis as a separate type of personality disorder, with this range of features, in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DMS-5). (Journal of Psychiatric Practice 2011;17:89–99) KEY WORDS: narcissistic personality disorder, therapeutic alliance, perfectionism, depressivity, suicide, psychoeducation

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INTRODUCTION People with narcissistic personality traits or fully developed narcissistic personality disorder (NPD) are expected to manifest rather specific features and behavioral patterns, such as dominance, arrogance, superiority, power seeking, and disregard of others. However, presentations of these individuals when seeking and receiving treatment in a clinical context may be quite different. Variable estimates of the prevalence of NPD, officially described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR)1 as a pervasive pattern of grandiosity (in fantasy and behavior) accompanied by a need for admiration and a lack of empathy, have been reported in different psychiatric settings (for an overview, see Ronningstam 20092), with the diagnosis found to be used more frequently by clinicians in private practice.3,4 The prevalence of NPD in the general population has been estimated to range between 0% and 5.3% in previous studies.2 A recent study, the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which used a different methodology, found a lifetime prevalence rate of NPD of 6.2% (7.7% for men and 4.8% for women) in the general population, with considerable psychosocial disability, especially among men, and co-occurring mood disorders (depression, bipolar I disorder), anxiety disorders, personality disorders, and substance use disorders.5

RONNINGSTAM: Harvard Medical School and McLean Hospital, Belmont, MA. Copyright ©2011 Lippincott Williams & Wilkins Inc. Please send correspondence to: Elsa Ronningstam, PhD, McLean Hospital, AOPC Mailstop 109, 115 Mill Street, Belmont MA 02478. [email protected] The author express appreciation to Steven Huprich, Ph.D., for valuable comments. The author declares no conflicts of interest. DOI: 10.1097/01.pra.0000396060.67150.40

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Researchers have for a long time argued for the existence of additional narcissistic features and additional phenotypic presentations of NPD, such as vulnerable self-esteem, perfectionism, feelings of inferiority, chronic envy, shame, and rage, feelings of boredom and emptiness, hypervigilance, and affective reactivity.6–11 Empirical studies have confirmed that internal emotional distress, interpersonal vulnerability, avoidance, fear, pain, anxiety, and a sense of inadequacy are associated with narcissistic personality functioning.12,13 Studies have also found that depressivity (i.e., features related to depressive temperament and depressive personality disorder) is related to hypersensitive narcissistic personality functioning14 (see below). NPD is defined by patterns of fluctuating and vulnerable self-esteem ranging from grandiosity (in fantasy or behavior) and assertiveness to inferiority or insecurity, with exceptionally high standards, selfenhancing and self-serving interpersonal behavior, intense reactions to perceived threats, and compromised empathic ability. It is differentiated from its near neighbors, primarily antisocial, borderline, histrionic, and obsessive-compulsive PDs, by the following characteristics: absence of recurrent antisocial behavior and less systematic and conscious exploitativeness (antisocial PD); absence of self-injurious behavior, identity diffusion, and intolerance of aloneness (borderline PD); lack of or impaired ability for interpersonal closeness and intimacy (histrionic PD, obsessive-compulsive PD); and perfectionism that is motivated more by status seeking, selfesteem, and avoidance of shame (NPD), than by a desire to maintain order and control and feelings of self-righteousness.15 The onset of Axis I disorders, such as major depression, substance use disorders, bipolar disorder, and posttraumatic stress disorder (PTSD), have been recognized as triggers that may lead individuals with NPD or narcissistic traits to seek psychiatric treatment. In such cases, however, the accompanying NPD or narcissistic traits may not be readily identified. Although narcissistic traits may sometimes be amplified by co-occurring Axis I symptoms (e.g., substance use, hypomania in bipolar disorder), they can also just co-occur with or remain hidden behind such symptoms.16–18 In addition, the variable phenotypic presentations in people with NPD, now verified in several studies, ranging from overt, grandiose, arrogant, and assertive, to covert, insecure, shy, and

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hypersensitive,13,19,20 correspond with the fact that NPD is found both in people who are high functioning12 as well as in those who are severely disabled.5 All of these factors make the clinical evaluation and identification of pathological narcissism and NPD especially challenging. The DSM-5 proposal to exclude NPD as a distinct type of PD21 would have particularly important consequences for ongoing efforts to identify, understand, and treat people with narcissistic personality traits and NPD. The current proposal for DSM-5 is to replace NPD by four separate personality trait facets: Narcissism, Manipulativeness, Histrionism, and Callousness, included under the trait domain Anta gonism. Other traits that have been clinically and empirically associated with NPD would be included under the domains Negative Emotionality, (i.e., Shame, Low Self-Esteem, Depressivity, and Anxious ness), and Compulsivity, (i.e., Perfectionism).22 Con tinu ing efforts to identify the complex clinical presentation and disruptive interpersonal functioning of people with NPD require that the diagnostic status of NPD be maintained. In a more detailed outline of evidence in support of keeping NPD as a personality type with a set of separate diagnostic criteria in DSM-5,23 I have suggested the following identifying criteria (adapted with permission from Ronningstam 201123 © The Guilford Press): Grandiosity, an enhanced or unrealistic sense of superiority, uniqueness, value, or capability ex pressed either overtly or covertly and internally Variable and vulnerable self esteem alternating between overconfidence and inferiority Strong reactions to threats to self-esteem including intense feelings (aggression, shame, and envy) and mood variations (irritability, depression, or elation) Self-enhancing and self-serving interpersonal behavior Aggressiveness Avoiding and controlling behavior and attitudes to preserve self-sufficiency and protect against affects and threats to self-esteem Fluctuating or impaired empathic ability Perfectionism and high personal ideals and standards, with strong reactions, including aggression, harsh self-criticism, shame, or deceitfulness, when failing to measure up.

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NARCISSISTIC PERSONALITY DISORDER: A CLINICAL PERSPECTIVE

The goal of this article is to highlight some of the central and seemingly incompatible clinical presentations of narcissistic traits and NPD, especially in the context of more atypical phenotypic presentations and their co-occurrence with depressivity and perfectionism. Implications for building a treatment alliance with a patient with narcissistically disordered character functioning are also discussed.

INDICATIONS AND SYMPTOMS OF DEPRESSION IN NPD In some patients with NPD, depressive symptoms may indicate a diagnosis of a depressive disorder, especially when they occur in the context of gradual or acute disillusionments, major losses, or other changes in these individuals’ lives that drastically threaten their self-esteem. The prevalence of depressive disorders in NPD has been estimated to be 42%–50%. 24 A specific type of depression found in middle aged and older narcissistic individuals is characterized by emptiness, meaninglessness, rumination about lost opportunities, or realizations of the negative self-undermining consequences of their persistent behavioral or interactional patterns.25 Acute depression as a reaction to severe narcissistic humiliation, defeat, failure, or loss of external affirmation, often in combination with suicidality, can urge the otherwise symptom-free narcissistic individual to seek psychiatric treatment. In such cases, the depression is usually an indication of self-depreciation, aggressive self-critical attacks, or loss of internal control. On the other hand, depressive symptoms or depressivity in narcissistic personalities can reflect either fleeting or more consistent characterological functioning related to fluctuations in selfesteem, internal struggles, and accompanying emotional dysregulation. Perfectionism, 26 self-criticism, aggressive self-attacks, and shame,27 which can be masked either by guilt28 or by aggression, 29 can represent notable signs of depressivity in narcissistic individuals. It is important to make such diagnostic distinctions early in treatment planning because depressive symptoms related to narcissistic character functioning require a different treatment approach. The identification of the two phenotypic presentations of NPD mentioned above—the covert, shy, sensitive type as well as the overt, assertive type—has stimulated new studies on narcissistic hypersensi-

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tivity and fragility, and it has spurred recent interest in the relationship between the depressive temperament and depressive PD and NPD. Predominant low self-esteem and feelings of inferiority and insecurity, combined with unattainable grandiose fantasies or inner convictions of unclaimed potential, as well as a proneness to shame and envy, can make hypersensitive narcissistic individuals specifically susceptible to depression. However, this predominant internal pattern might also represent a pervasive characterological depressive functioning. Rathvon and Holmstrom suggested that the covert aspect of narcissism is associated with depletion,30 and Cooper highlighted the self-defeating masochistic aspects of NPD expressed in humiliating interpersonal interactions and repeated failures in aims and ambitions.7,31 In a review on depressive PD, Huprich identified several features of depressive PD that are also central to hypersensitive narcissistic personality functioning.14 These include aggression, self-criticism, masochism, and avoidance of or hyper-reactivity to criticism from others. Tritt and colleagues found that vulnerable and maladaptive narcissistic traits were positively associated with depressive temperament, especially avoidance of narcissistic injury and oversensitivity to the lack of admiration from others.32 Despite the limitations of this study that were acknowledged by the authors (i.e., subjects being nonclinical female college students so that the study should be repeated with interviews of subjects screened for clinical depression), it still raised important questions about a potential component of depressivity associated with certain aspects of narcissistic personality functioning. In a recent study in a clinical sample, Huprich and colleagues found that measures of both depressive PD and hypersensitive narcissism were associated with feelings of alienation, fears of being in an insecure or stranded relationship, excessive focus on one’s own needs, and a sense of social inadequacy (Huprich, Lunchner, Roberts, and Pouliot, unpublished data). They also found that hypersensitive narcissism was related to hypersensitive selffocus and self-consciousness as well as to critical judgments of others. Huprich and colleagues proposed that the relationship between the two constructs involves disruptive patterns of interpersonal relatedness. Paradoxically, people with NPD can also be remarkably free of depressivity and overt symptoms of depressive disorders. Intolerable affects, evoked by

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life events that threaten self-esteem, such as loss of vital support, aspirations, and perfectionistic ideals, can be effectively denied and split off.33–35 While narcissistic grandiosity and self-enhancement have often been considered incompatible with depressivity, such features can also effectively hide depression or depressive experiences. Hyperactivity, competitiveness, and accompanying successful functioning in some people can, for a while, effectively cover underlying depressivity. In other individuals, argumentativeness, irritability, and aggressivity, combined with various self-serving and self-enhancing behaviors, can provide an effective armor against depression. Substance use, especially when combined with some ability to maintain high and successful functioning, may also serve such a purpose. A differential diagnostic evaluation vis-à-vis bipolar spectrum disorders and substance use disorders may be indicated. The prevalence of comorbid bipolar disorder in NPD is estimated to be 5%–11%, while that of concomitant substance use disorders is estimated to be between 24% and 50%.24 Suicidal ideation and behaviors, usually considered reliable indicators of depression, can occur in the absence of depression in narcissistic patients,33,36–38 or be driven entirely by subjective experiences of mental pain.39,40 Narcissistic patients may also abruptly commit suicide in a state of rage or despair. 37,41,42 Sustaining suicidal fantasies can help to maintain internal control and ward off intolerable feelings such as rage, shame, envy, hopelessness, and experiences of limitations.43 Such fantasies can contribute to keeping the narcissistic individual alive because they may preserve a sense of internal mastery and control, or they may shield against anticipated narcissistic threats and injuries, as the motto “death before dishonor” implies. 44,45

PERFECTIONISM AS AN OBSTACLE OR A VEHICLE IN TREATMENT Perfectionism has been associated with grandiosity in narcissistic personalities. However, while grandiosity is defined as an exaggerated self-experience with enhanced or unrealistic self-appraisal that is closely associated with grandiose fantasies, perfectionism is a multifaceted and complex trait involving ego-ideals and self-criticism, in addition to affective reactivity and cognitive appraisal of both self and others.11,46 Recent research has identified the self-enhancing,

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competitive, and self-promoting aspects of perfectionism (i.e., the perfect self-presentation, as well as the self-protective aspect, especially when assessing interpersonal situations, including hiding or not admitting one’s own imperfections to avoid being seen as imperfect). 47 Perfectionism in narcissistic personality functioning serves to enhance self-esteem and selfpresentation, and to avoid tormenting self-criticism and underlying feelings of shame and inferiority.48 It also serves self-protective functions by concealing or allowing the person to avoid admitting imperfections. Immediate threats to perfectionistic standards, especially critical and aggressive reactions, can escalate narcissistic symptoms. These findings concerning the function and expressions of perfectionism provide a strong argument for its inclusion as a diagnostic criterion for NPD. When perfectionism co-occurs with realistic selfassessment, capability, and opportunities for productive or creative work and achievement, it can be a very important incentive for personal growth and professional success. On the other hand, in a negative or maladaptive form, perfectionism can be associated with doubts, excessive concerns about mistakes, and hypersensitivity to the expectations of others.49,50 In this situation, perfectionism is driven by exceptionally high or unrealistic standards and is detached from regular self-criticism; thus, when/if the person fails to measure up to such standards, this can evoke intense inner agony, feelings of inadequacy, avoidance, and depression. In the context of projected or actual failures or losses, perfectionism can also co-occur with anticipated social mortification and disgrace in the eyes of other people. On a more severe level, perfectionism has been linked with shame, hopelessness, suicidal ideation, and suicidality, as well as with several psychiatric conditions that can co-occur with NPD, including alcoholism, depression, anxiety, obsessive-compulsive disorder, and eating disorders. 26,49–51 Perfectionism naturally leads to a reluctance to acknowledge one’s own imperfections or to be seen as imperfect. Consequently, for narcissistic individuals, difficulties engaging in and building a positive alliance with a therapist, and reluctance or inability to disclose distress and problems related to imperfections can cause treatment stalemate, disruption, and negative outcomes.26,46,47 While some narcissistic individuals readily announce their perfectionistic strivings and ideals,

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often in combination with their contempt for the perceived imperfections of other people, for others their perfectionism works secretly and effectively as a vehicle for internal control and regulating selfesteem. In hypervigilant narcissistic individuals, their combined self-oriented and other-oriented perfectionism can serve to maintain both control and distance.52 Even experienced clinicians can find such patterns difficult to discern. On the other hand, acknowledging the consequences of their perfectionistic strivings can serve as a turning point for some people and can motivate them to engage in selfexploratory and reflective treatment. The following case vignette illustrates such a development. Case Vignette 1 Patient 1, a very promising and professionally successful man in his late 30s, was hospitalized after a suicide attempt. This attempt followed a period of increased anxiety and avoidance that had gradually had a negative impact on his otherwise excellent work performance. He had been called on mistakes, had failed to follow up on decisions and changes, and had missed important staff meetings. He felt increasingly confused and was struggling with harsh self-critical attacks and self-doubt; he ...