12b
Elsa Ronningstam and Tiffany Russell
Narcissistic personality disorder, NPD, and histrionic personality disorder, HPD, are presently undergoing major changes in status, as well as clinical and empirical credibility and utility. While NPD has gained increased attention, HPD is facing difficulties foremost due to cultural and functional specifics. The chapter by Dawood, Wu, Bliton, and Pincus (this volume) provides a most timely and valuable overview of recent research and reconceptualizations that can broaden the clinical identification of these personality disorders. Studies of NPD, in particular, show significant advances in identifying multifactorial components that impact narcissistic symptoms and personality function.
In this commentary, we discuss issues that significantly influence narcissistic personality function and clinical presentation beyond the nucleus diagnostic conceptualization of NPD. We will also address some additional factors that affect level of functioning, sense of agency and control, and the Dark Triad with aggression and violence.
Clinicians treating patients with pathological narcissism (PN) or NPD in different settings and modalities are often struggling with these patients’ unexpected and varied presentations and fluctuations. Clinicians as well as patients’ negative reactions can readily evoke transference-countertransference enactments with risk for early dropout (Ellison, Levy, Cain, Ansell, & Pincus, 2013; Gamache, Savard, Lemelin, Côté, & Villeneuve, 2018; Kacel, Ennis, & Pereira, 2017). All this has contributed to an inequitable negative view of NPD with questions about its treatability (Kernberg, 2007).
Incorporating a dimensional approach as outlined in DSM-5 Section III AMPD substantiates the clinical complexity of NPD, which is influencing patients’ engagement in and ability to benefit from treatment (Ronningstam, 2014). Dawood et al. (this volume) acknowledge that the dimensional diagnostic approach can help clinicians to identify a wider range of PN and NPD, and describe NPD in terms that can be more informative and helpful for the patients. The Personality Inventory for the DSM-5 (PID-5; Krueger, Derringer, Markon, Watson, & Skodol, 2012) is a dimensional personality instrument corresponding with the AMPD, and including the five personality domains (Negative Affectivity, Antagonism, Psychoticism, Disinhibition, and Detachment). The Antagonism domain captures interpersonal challenges found in both grandiose and vulnerable narcissism. Facets of Negative Affectivity and Psychoticism account for dysregulation, contingent self-esteem, and entitlement rage seen in vulnerable narcissistic personality functioning (Wright et al., 2013). Consequently, PID-5 may also provide a way to integrate additional constructs like the Dark Triad and its more vulnerable counterpart into the diagnostic assessment and clinical applications of NPD
Dawood and colleagues’ (this volume) review of research highlights different aspects of NPD functioning related to range of personality functioning: the inter-correlation between grandiose versus vulnerable, and overt external versus covert internal expressions of pathological narcissism, as well as co-occurrence with other psychiatric conditions. Recent research studies have provided a more comprehensive conceptualization of pathological narcissism (i.e., pointing to neuropsychological and neurological deficits as well as significant indicators of functioning across multiple domains including self-esteem emotion regulation, attachment patterns, and agency). These new facts and perspectives can guide clinical interventions beyond the trait-based conceptualization, and offer a more reliably explanatory connection between personality functioning, clinical presentations, and the diagnosis of NPD (Ronningstam, 2014, 2017).
Significant efforts are ongoing to improve assessment to capture co-occurrence and fluctuations between grandiose and vulnerable core features in NPD. However, this area still needs empirical attention and clinical reformulations as its multifactorial complexity goes far beyond the intersection between overt and covert aspects of the grandiosity–vulnerability oscillation as suggested by the authors. Stability versus oscillation between high competent and low impaired functioning, primarily related to ability to work and relate, represents one such range factor with major implications for the grandiosity–vulnerability balance. The concept of agency (Fonagy, Gergely, Jurist, & Target, 2002) and its relationship to narcissism has been connected to narcissistic personality functioning. Sense of agency is influenced by perceived accomplishments, perfectionism, and sense of control (internal and external), as well as by self-criticism, psychological trauma, and fear, and it plays a significant role in the individuals’ assessment. Sense of agency can be especially consequential for people whose self-worth is fragile and ability for interpersonal relativeness compromised. Loss of sense of agency and control, with accompanying failure to sustain self-enhancement or live up to standards can escalate intense or determined suicidal ideations (Links & Prakash, 2013; Ronningstam, Weinberg, & Maltsberger, 2008).
The authors review research identifying comorbidity in NPD and mechanisms driving the co-occurrence of specific symptoms such as anxiety, mood disorder, and substance use. This is also of significant clinical importance, as the interaction between pathological narcissistic personality patterns and such comorbid conditions can have major impact on diagnosis and treatment of either or both conditions. Specific symptoms can paradoxically, when co-occurring with NPD, temporarily enhance internal control, self-esteem, competence, and achievements related to more grandiose strivings, and shield against insecurity and vulnerability Those include mood elevation in bipolar disorder, or the explicit psychological or physiological impact of a certain substance in substance use disorder (Benton, 2009). Consequently, such interaction will reduce motivation for treatment. Especially the co-interaction between elevated mood and narcissism can be confusing as patients’ insecurity, fear of failure, or avoidance suddenly can switch into confidence and high aspirations with disruptions of treatment. The importance of longitudinal perspective on this interactions is highlighted by the finding that during manic and hypomanic episodes most bipolar patients exhibit a majority of NPD trait criteria, whereas only 11 percent of euthymic bipolar patients fulfill the diagnosis of NPD (Stormberg, Ronningstam, Gunderson, & Tohen, 1998).
Aggression and Violence
Aggression has long been considered a core aspect of pathological narcissism and NPD, either as an inherited constitutional drive (Kernberg, 1992), or a prime reaction to frustration, threats, and/or humiliation (Kohut, 1972). Narcissistic self-esteem regulation with self-enhancement and vulnerability is connected with a range of aggression, both internal and self-directed as well as external and interpersonal, including irritability, criticism, resentment, vindictiveness, rage, and hatred (Rhodewalt & Morf, 1998).
Severe aggression and violence associated with the Dark Triad is another area of research that needs further integration in the overall conceptualization of NPD. The Dark Triad (i.e., psychopathy, grandiose narcissism, and Machiavellianism; Paulhus & Williams, 2002) has received considerable attention in social and personality research, though the findings are rarely integrated into clinical science and practice. While each of the “dark” personalities contribute distinctive traits to the triad (e.g., narcissistic grandiosity), the cluster shares a common dark core of callousness and manipulativeness. These traits seem to account for the moderate inter-correlation between these personalities (Jones & Figueredo, 2013) and explain aspects of Cluster B comorbidity with greater specificity. Building on this concept of the Dark Triad, Miller and colleagues (Miller et al., 2010) proposed a vulnerable Dark Triad comprised of vulnerable narcissism, borderline personality disorder, and Hare’s (1991) factor 2 psychopathy (i.e., irresponsible, impulsive, and sensation-seeking behaviors). This model would thus include interpersonal antagonism, emotional dysregulation, and vulnerability, which is a “dark” core of traits commonly found in clinical settings. However, additional work is required to determine more precisely the aspects that each personality type contributes to a vulnerable Dark Triad.
Narcissism is also related to sexual violence. Psychological reactivity, or an increased desire for something forbidden, may be related to sexual aggression in men with high levels of narcissism, as they are particularly reactive when denied something they desire. This reactivity seems interconnected with entitlement and an underlying sense of insecurity (Baumeister, Catanese, & Wallace, 2002; Bushman, Bonacci, van Dijk, & Baumeister 2003; Zeigler-Hill, Enjaian, & Essa, 2013). Entitlement in men can predict trait anger, negative attitudes towards women, sexual dominance, and a preference for impersonal sex (i.e., unrestricted sociosexuality; LeBreton, Baysinger, Abbey, & Jacques-Tiura, 2013). Narcissistic traits also indirectly predicted sexual violence in men (Russell & King, 2017), as well as sexual aggression and coercion in women (Russell, Doan, & King, 2017).
Fear and Trauma
Fear in NPD can readily be connected with Axis I anxiety or social phobia rather than with specific narcissistic dynamics and challenges. Such challenges can involve concrete external events as well as internal subjective or emotional experiences related to losing internal control, not measuring up or failing, and losing status, affiliation, or power. Overwhelming and consuming experience of fear can cause lapses in decisions, or force drastic decisions with seemingly immediate short-term gains. Considered a self-regulatory factor (Bélanger, Lafrenière, Vallerand, & Kruglanski, 2013) fear of losing control is related to narcissistic core features, such as self-enhancement with ambitions, competition, perfectionism, and aspirations. In addition, avoidance and procrastination, and even risk-taking efforts can all enable ignorance or modulation of fear (Ronningstam & Baskin-Sommers, 2013)
Trauma has also been connected to NPD in trauma associated narcissistic symptoms (TANS) (Simon, 2002). Those are caused primarily by an internal self-experience or by the subjective experience of an external event that threatens the continuity, coherence, stability, and well-being of the self. Sense of failing competence, with loss of self-esteem, standards, and self-worth, or loss of affiliation and connections to others, become overwhelming, intolerable, and even terrifying. Efforts to understand and find meaning in the experience fall short and the usual narcissistic self-regulatory and defensive strategies fail (Maldonado, 2006). Narcissistic psychological trauma related to losses, inconsistencies, and neglect can be implicit, somatized, and psychophysiologically contained in the body leading to difficult-to-regulate emotions and interpersonal relatedness. When such trauma co-occurs with depression it can be associated with self-organizing negativity (negative self-narrative; Ginot, 2012) linked to narcissistic self-esteem and identity (e.g., “I am the most hated member of my family” or “ the most degraded staff at my workplace”). When combined with avoidance, this can perpetuate both underlying narcissistic pathology as well as the major psychiatric condition. In such interactions, it can be difficult to identify the co-occurring and usually covert or hidden narcissistic pathology that tends to perpetuate depressive symptoms. Consequently, such co-occurring conditions can be misdiagnosed as the impact of NPD remains unidentifiable.
Suicide
Suicidality can serve narcissistic functions, both when kept as an intention or fantasy that helps to sustain internal control (“I know that I can end my life if things do not go my way”), and when leading to actions in an effort to escape unbearable circumstances related to loss, failure, or humiliation. Suicide can also serve as a way to retaliate as the underlying narcissistic investment in the meaning and consequences of suicide can motivate and have an empowering effect. NPD related suicides are characterized by absence of depression, rage-shame escalation, and high lethality (Ronningstam, Weinberg, Goldblatt, Schechter, & Herbstman, 2018). Paradoxically suicide can serve to preserve self-regard, superiority, and triumph over defeat, to achieve sadistic control over others, or as an exit from uncontrollable situations (Kernberg, 1992, 2007)
Conclusion
There is significant value in the integration of different modalities of research on narcissism and NPD across multiple areas in psychology and psychiatry with longstanding clinical and psychoanalytic accounts. Integrating the hybrid AMPD can keep some of the original conceptualizations of narcissistic pathology on the cutting edge of psychological and neuropsychological science. Our prime aim is overall to optimally enhance our understanding and treatment of this complex personality condition, and Dawood and colleagues’ chapter (this volume) represents an important step in that direction.
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