Both clinical and empirical studies have confirmed that emotional distress, interpersonal vulnerability, a sense of inadequacy, need for control, avoidance, and fear, pain, and anxiety are important facets of narcissistic personality functioning.
Co-occurrence and fluctuations between self-enhancing grandiosity and self-depreciating vulnerability are also present in narcissistic pathology.
Typical indications of narcissistic vulnerability include inferiority and insecurity, avoidance, shyness, hidden aggressive reactions, shame, and persistent self-negativity.
Paradoxically, hidden excessive self-negativity can also serve empowering, protective, and controlling functions.
Additional characteristics frequently found in patients with NPD are perfectionism and high standards accompanied by self- and other-directed criticism, as well as by preoccupation with fear of not meeting standards and of failing.
In addition, chronic envy, rage, boredom, and emptiness can co-occur with hyper-vigilance and defensive emotional reactivity, especially aggressivity, criticism, and dismissiveness.
NPD – An Alternative Model
A proposed hybrid model with combined diagnostic dimensions and traits was included in DSM-5, Section III Alternative Model for Personality Disorders, AMPD, (APA 2013).
This diagnostic model identifies specific difficulties and impairments in personality functioning, i.e., in identity and self-direction related to self, and empathy and intimacy in relation to others. In addition, there are specific personality traits that signifies each personality disorder.
The typical features of NPD (pages 767-768) attend primarily to the vulnerable and fluctuating self-esteem and the range of interpersonal patterns.
Moderate or greater impairment in NPD is found in the following areas of personality functioning:
- Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal—inflated or deflated or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem.
- Self-direction: Goal-setting based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
- Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimates own effects on others.
- Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.
Two personality traits identify NPD:
- Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending towards others.
- Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (2013). American Psychiatric Association.
This NPD diagnosis is defined as a combination of significant problems within the 4 areas of personality functioning and at least 1 of the two personality traits.
In addition, impairment in functioning and trait expressions should be persistent across different personal and social situations, stable over time, not explained by other mental or medical conditions, and evaluated in the context of the individual’s developmental stage and sociocultural context.
This new diagnostic model is more clinically meaningful and informative for both patients and clinicians. It is descriptive and captures a broader range of narcissistic personality functioning, including fluctuations and variations in both context and severity of pathology.
It also invites attention to individual motivation and self-regulatory internal as well as interpersonal patterns and intentions. It connects fluctuations in self-esteem, i.e., superiority and inferiority, with identity problems, and inconsistent goals and motivation.
Foremost, this model focuses on the complex interpersonal functioning, i.e., the need for others’ support of own self-esteem and sense of identity, combined with self-preoccupation, compromised ability for empathy, and inattentions to others’ needs and reactions. In sum, fluctuations in personal, internally driven self-enhancement co-occur with intense needs for others’ attention and admiration, as well as with distancing and disinterest in relationship to others.
Still being a proposed model for diagnosis of personality disorders, this model is presently guiding continuing research on identifying pathological personality functioning and disorders.
Individuals With Pathological Narcissism or NPD
Individuals struggling with pathological narcissism or NPD can come across quite differently; there is no real standard prototype.
Some individuals are professionally successful, consistently high-functioning, and socially well-connected, only showing reactivity, distancing, and avoidance in certain contexts.
Others can present with functional fluctuations or specific impairment, either with severely disabling narcissistic traits and character functioning, or with accompanying mental disorders, such as mood disorder (major depression, dysthymia, bipolar disorder), substance use disorder, or eating disorder, or obsessive compulsive disorder.
Some individuals can have accompanying somatic conditions that in different ways affect their self-esteem, motivation, or sense of identity. Still others can engage in occasional illegal behavior, and those with more severe malignant narcissism can have antisocial or psychopathic behavior such as violent revengefulness, exploitation, and hostility.
Fluctuations in pathological narcissism and changes towards worsening as well as improvement in narcissistic personality functioning are often influenced by real life events (e.g., vocational, social, interpersonal, marital, or family, medical, or financial).
Such events can be perceived or experienced by the individual as threatening or corrosive in ways that escalate pathological narcissistic traits and functioning.
Alternatively, they can also be experienced as supportive, confirming, and encouraging or even corrective, leading to new realizations, stabilized self-esteem, and decreases in pathological narcissistic functioning.
People with pathological narcissism or NPD may have strengths and abilities in certain areas, i.e., in their professional or social lives, or in certain types of relationships, which they find supportive of their self-esteem, sense of identity, and/or interpersonal functioning.
However, they can still present with severe vulnerabilities or external pathological narcissistic patterns in other areas: especially in intimate relations, parental roles, certain social, professional, or work-related situations, or in their moral and ethical standards or behavior.
Consequently, people with NPD can experience themselves and come across differently in different social or interpersonal contexts. The same person may feel confident and competent, or act in a convincingly dominant and assertive way in one setting. In another they may feel shy and avoidant, or insecure, easily humiliated, and struggling with loss of control, feelings of envy or resentment, or with fear of failing or being exposed.
In addition, certain circumstances and experiences can evoke or aggravate narcissistic traits in response to challenging or traumatic experiences. This can evoke interpersonal provocative, critical, and aggressive behavior.
Some experiences can be perceived as traumatic because they take on a subjective frightening meaning, or can activate earlier narcissistic trauma, which consequently can threaten the person’s self-esteem, and sense affiliation, coherence, stability, and well-being. On the other hand, certain events and experiences can readily be seen as organizing and consoling, and hence enabling access to proactive confidence.
Some people choose to take on narcissistic pathology as a sense of identity, presenting themselves as “I am a narcissist,” especially in response to being told or accused of “being narcissistic” or having NPD.
Such self-characterization may paradoxically serve an empowering function that can help to shield actual internal vulnerability or interpersonal struggles related to self-esteem and emotions.
Ability for self-reflection and forming coherent meaningful narratives of deeper personal experiences is often compromised.
Recognizable Individual Variations
When people with pathological narcissism or NPD seek treatment they can present in many different ways. Some match the typical expectation of a narcissistic personality by being self-promoting, self-absorbed, and interpersonally provocative. Others effectively hide their narcissistic characteristics and can initially be friendly and tuned in, but gradually turn distant and aloof.
Some individuals present with corrupt and antisocial traits, while others take pride in their high moral and ethical standards. Some are boastful, assertive, and arrogant; others can be modest and unassuming with an air of grace; and yet others can present as perpetual failures while constantly being driven by unattainable, grandiose aims.
One person can be charming and friendly, another shy, quiet, and vulnerable, yet another domineering, maneuvering, aggressive, and manipulative.
When people with pathological narcissism or NPD seek treatment they can present in many different ways.
Some are intrusive and controlling; others are evasive and avoidant. Some can openly and bluntly exhibit most extreme narcissistic features and strivings, but still hide more significant narcissistic personality problems. Others are perfectionists, driven by high standards, and extreme demands both related to themselves and others.
Absence of symptoms and experiences of suffering can be a paradoxical blessing for some people with NPD. Others, however, can struggle with severe internal suffering, including harsh self-criticism, self-doubt, fear, shame, insecurity, and anger that may or may not be expressed.
Some individuals can provide well-informed and articulate accounts of their pathological narcissistic functioning with insights in interpersonal patterns or contributing developmental experiences. Others may be totally oblivious of their problems, assigning blame on others, or even feeling forced to seek treatment.
Nevertheless, the common indications of narcissistic personality functioning include apparent or concealed self-enhancement with self-esteem fluctuations, vulnerability, and inferiority, and fear of losing control and failing. Avoidance, control, and distancing are key patterns.
Ambiguity and fluctuations in sense of identity are common. Some may be aware of their limitations in interpersonal relationships, with compromised empathic functioning and intense reactions to criticism and threats to self-esteem, with strong need for control.
Others tend to primarily externalize and criticize others. Still others may take charge of their diagnosis and identify with several of the common traits without identifying and taking ownership of their own real problems.
Internal Struggle and Reactivity
Contrary to the external confidence, arrogance, and insensitivity, people with pathological narcissism and NPD tend to struggle with a shifting and conflicting sense of self and identity. Underneath a more noticeable self-praising or self-enhancing outward facade they can be excessively self-critical and judgmental. Some struggle with perfectionism and exceptionally high standards for themselves, and sometimes for others too.
Strong reactions to perceived threats to self-esteem, such as humiliation, defeats, criticism, failures, or others’ envy, are common.
Such reactions can include intense feelings that are either openly expressed or hidden (anger/hostility, envy, shame, or fear), mood shifts (irritability, anxiety, depressive symptoms, or elation), or deceitful or retaliating behavior (aggressive, antisocial, or suicidal behavior).
Strong reactions indicate fluctuations in self-esteem, which can alter between states of overconfidence, superiority, and assertiveness, and states of inferiority, insecurity, and incompetence (grandiosity and vulnerability).
In addition to not knowing their own motivations, people with NPD can also have a compromised sense of identity and not knowing who they really are or what they want. Their sense of self-agency, i.e., goals, directions, and determination, is influenced by a need for internal control, a sense of self-sufficiency, and avoidance of threats or challenges to self-esteem, with a reluctance or inability to rely on others.
Self-enhancement and self-preoccupation serve as a protective armor by shielding or hiding low self-esteem, harsh self-criticism, insecurity, inferiority, shame, loneliness, detachment, and fear.
This excessive internal self-negativity, often mistakenly perceived as depressive disorder, can paradoxically be part of the narcissistic self-enhancement by providing self-defining control and justifying avoidance (“I am a failure,” “I do not deserve,” “Nobody can understand or help me,” “I am my own worst enemy,” etc.).
Signs of individuals’ narcissistic traits or functional patterns have often been identified in their interpersonal interactions.
Spouses, relatives, friends, or colleagues can notice an avoidant distancing pattern with lack of motivation to relate closely, or alternatively, an eager attention seeking preoccupation with expectations or demands on others to satisfy their needs and longings.
Entitled, arrogant, aggressive, or competitive ways of relating can be typical for some. Others can be extraordinarily attentive, reliable, and tuned in as long as they feel they get the approval or support they need, while some typically show a more consistent critical, dismissive, or devaluing attitude or way of relating.
People with pathological narcissism or NPD can be both vulnerable and insensitive to others’ feedback. They are vigilant to perceived rivalry and rejections and may readily take on an empowering victim role, blaming others for not being able to measure up to their own standards.
Tendencies to combat and retaliate towards alleged criticism or disagreement is common, but retreat into self-sufficiency or self-absorption without noticeable reactions can also be an engrained pattern. Longstanding envy, resentment, or animosity can spur further distancing.
Especially in long-term relationships, enduring combative, retaliating patterns can co-occur with dependency and even love.
Some people may easily feel criticized, degraded, mistreated, or ignored by the person with pathological narcissism, but some may feel, at least partially or intermittently, highly valued, idealized, and relied upon.
In higher functioning people with more compartmentalized pathological narcissism, longstanding constructive, collaborative relationships may co-exist with other deeply conflictual, distant, or contentious personal relationships.
Difficulties to access, identify, tolerate, and verbalize emotions are typical for individuals with pathological narcissism or NPD.
Such deficits affect their ability to maintain close, mutual relationships. Tendencies to extract, avoid, or isolate from others can be a way to sustain superiority and self-enhancing fantasies, i.e., a “splendid isolation,” but such removal from others can also be driven by shame and fear of exposure or failure.
The ability to work, and to remain devoted to professional commitment both in times of success as well as during challenges and setbacks, are significant indications of agency and sustainable competence that can be present in higher functioning people with NPD.
For those who successfully worked under stable conditions for decades, sudden changes, setbacks, or interruptions in their work context can be narcissistically traumatizing, leading to excessive self-doubts, self-criticism, and loss of professional identity.
Some individuals can have exceptional abilities in creativity, innovation, or leadership and be more project oriented. Others can present with temporary achievements and a history of occasional or irregular accomplishments, or a one-time top achievement under favorable circumstances.
All of this can indicate actual or potential capabilities that are hampered by changes in vocational conditions or by fluctuations or vulnerabilities in self-esteem or interpersonal relations.
However, such transient achievements can, for some people with less sustaining capability, be the result of favorable temporary circumstances that support self-enhancing and self-serving behavior.
Individuals whose work includes both own expertise as well as team collaboration or leadership can repeatedly find themselves in unmanageable situations, feeling threatened, dismissed, or intruded upon by others’ opinions and demands.
Aspirations and envisions of outstanding success and accomplishments are common and natural in young people facing the beginning of their educational and professional careers.
The balance between self-esteem and direction, and the integration of experiences of success and disappointments with realizations of competence and limitations are essential for continuing functioning and developing of vocational identity and direction.