According to the DSM-5 Section III criteria the main features of narcissistic personality disorder (NPD) are grandiosity and attention-seeking, with other characteristics being unreasonably high standards to prove exceptionalism, unreasonably low standards due to entitlement, superficial relationships that are to improve self-esteem, problems identifying others needs and feelings, need for admiration, belief of superiority, and condescension towards others (Oldham, Skodol, & Bender, 2014). The Section III alternative model reflects that people with NPD can have either grandiose or vulnerable narcissism, and some patients fluctuate with symptoms of both (Oldham et al., 2014; Zeigler-Hill, Green, Arnau, Sisemore, & Myers, 2011). Vulnerable narcissism is characterized by both emotional dysregulation and self dysregulation which can be social withdrawal, self criticism, feelings of shame and/or anger, negative view of self, and interpersonal sensitivity (Zeigler-Hill et al., 2011).
On the other hand, grandiose narcissism is characterized by exploitation of others, exhibitionism, and an overly positive view of self (Zeigler-Hill et al., 2011). There is no definitive cause for narcissistic personality disorder, however there are theories that attempt to give a reason for its manifestation. Early maladaptive schemas (EMS) is a model proposed by Young and his colleagues, where traumatic or repeated negative interactions can lead people to developing schemes which support their maladaptive perceptions of themselves, others, and relationships (Zeigler-Hill et al., 2011). According to a study done by Zeigler-Hill and colleagues (2011), the entitlement and mistrust schemas are positively associated with both forms of narcissism, grandiose narcissism had positive associations with the unrelenting standards and self-sacrifice schemas, along with a negative association with the insufficient control schema, whereas vulnerable narcissism had positive associations with subjugation and abandonment schemas, along with a negative association with the dependence schema. This indicates that at the core of NPD is a sense of entitlement and a fundamental mistrust of others, and these traits may drive the other schemas or symptoms. The schemas associated with grandiose narcissism indicate that perfectionism is a major component of this subtype of narcissistic personality disorder. Whereas the schemas associated with vulnerable narcissism are indicative of the role of mistrust in driving the fear of abandonment and the need to not be dependent on others.
Since narcissistic personality disorder has two different expressions with many possible symptoms and maladaptive thinking patterns, it’s also comorbid with many other psychological disorders. NPD is often comorbid with other personality disorders, with the most common being antisocial, histrionic, borderline, and schizotypal (Caligor, Levy, & Yeomans, 2015). Other common co-occurring disorders are substance use disorders and bipolar disorder (Caligor et al., 2015). However when splitting into the two subtypes other comorbidities are also present. Grandiose NPD subtype is comorbid with paranoid PD, antisocial PD, and substance abuse, whereas vulnerable NPD subtype can co-occur with depression, anxiety, nonsuicidal self-injury, and suicide attempts (Caligor et al., 2015). Prognosis is the most negatively affected when NPD is co-occurring with antisocial personality disorder (Caligor et al., 2015). Narcissism has also been found to be linked to alcohol use. Grandiose narcissism was found to predict alcohol use and problem evaluation, whereas vulnerable narcissism was found to predict alcohol-related problems, problem recognition, and problem expectations (Welker, Simons, & Simons, 2018).
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Narcissistic personality disorder is one of the least studied personality disorders, especially in regards to treatment. According to a study done by Furnham, Kirkby, and Mcclelland (2010), NPD was the least recognized as being an illness, while also being regarded as the least likely to need treatment and least likely to be cured by lay people. A major problem with treatment of NPD is that people with this personality disorder are some of the least likely to utilize treatment services and have high rates of treatment dropout (Ellison, Levy, Cain, Ansell, & Pincus, 2013; Caligor et al., 2015). There are a handful of reasons a person with NPD may seek treatment: crisis from personal failures, being forced by family or an employer, mandated by court, dissatisfaction with life, substance abuse, anxiety, or PTSD (Ronningstam, 2011).
Another instance where a person with NPD may need treatment, is while they are undergoing medical treatment for a chronic and/or serious illness. Psychotherapy may be needed alongside medical treatment due to the person with NPD having low tolerance for distress, expecting special treatment (e.g must be treated by Attending Psychologist, or treated during a federal holiday), not adhering to treatment plans, difficult relationships with their medical team, poor boundaries, rejecting help, and self-sabotaging behavior (Kacel, Ennis, & Pereira, 2017). In the scenario of having psychotherapy alongside medical treatment some patients may want to undergo long-term treatment, whereas others may want problem-focused treatment so they can move forward and handle medical treatment (Kacel et al., 2017). There currently is not robust empirical evidence for psychotherapy or psychopharmacological treatments, nor are there clinical practice guidelines for narcissistic personality disorder (Kacel et al., 2017).
Some treatment options such as mentalization-based therapy, transference-focused psychotherapy, and schema-focused psychotherapy are adapted forms of empirically supported borderline personality disorder treatments (Kacel et al., 2017). If NPD is comorbid with borderline personality disorder another option for treatment would be dialectical behavior therapy (Kacel et al., 2017). Treating NPD in general is difficult, one of the first major obstacles is trying to establish a therapeutic alliance with the patient. According to Kacel and colleagues (2017), patients with NPD may not fully engage with the therapist early in the treatment phase. Confrontations that can strain the alliance are also common with NPD, these clients can devalue the therapist or criticize and complain about the therapist or the therapy itself (Oldham et al., 2014). Therapists should monitor themselves and be cautious of reacting negatively to patients (Kacel et al., 2017). Since clients with NPD can have significant interpersonal problems, group therapy may be useful in conjunction with individual therapy.
However, NPD can complicate the group therapy process by taking the monopolizing, boring, and/or help-rejecting roles in the group (Oldham et al., 2014). A case study on metacognitive interpersonal therapy in groups (MIT-G) has shown success and more studies should be done on NPD in group therapy (Popolo et al., 2018).
Narcissistic personality disorder is characterized by the antagonism traits of grandiosity and attention-seeking, with other core features being entitlement and mistrust which all interact and affect interpersonal relationships, perceptions of themselves, and perceptions of others. Narcissistic PD has two subtypes: grandiose and vulnerable, grandiose being more recognizable due to its exhibitionism and excessively high view of self, and vulnerable having significant problems with emotional and self dysregulation. It’s often comorbid with other personality disorders, substance use disorders, bipolar disorder, depression, anxiety, alcohol use, and can have problems with nonsuicidal self-injurious behavior and suicide attempts.
People with NPD are unlikely to seek out treatment for their personality functioning, and typically go into treatment due to ultimatums, being court mandated, or symptoms from other comorbid mental health issues. Treatments that work for borderline personality disorder can be adapted to treat narcissistic PD. Patients with NPD are likely to terminate treatment early, therefore establishing a therapeutic alliance and handling confrontations is critical to having successful treatment.
Although there has been little research on group therapy with patients with narcissistic PD, some research has indicated that it could be beneficial in helping with interpersonal problems and understanding others. As one of the least studied personality disorders more research should be done to empirically validate current treatment options and to better understand the two subtypes of narcissistic personality disorder.
References
- National Center for Biotechnology Information: The Narcissism Epidemic
- The Journal of Nervous and Mental Disease: Vulnerable Narcissism and Emotion Dysregulation
- Frontiers in Psychology: The Role of Schemas in the Relationship Between Self-esteem and Vulnerable Narcissism
- Canadian Journal of Psychiatry: A 5-Factor Model Perspective on Grandiose Narcissism from the Perspective of Adult Attachment Style
