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Narcissism and Psychopathological Profiles: Definitions, Clinical Contexts, Neurobiological Aspects and Clinical Treatments

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Abstract

Starting from the general concept of "narcissism", the present work focuses on the essential aspects of personality disorder that define the clinical and diagnostic contexts, laying the foundations for correct differential diagnosis, without neglecting the neural characteristics developed by the scientific community. A new classification of the narcissistic disorder is presented that better defines the different types, in a more general framework of the "narcissistic spectrum". The discussion ends with the best suggested therapeutic approaches.
Journal of Clinical Cases and Reports
ISSN: 2582-0435 Clinical Review | Vol 4 Iss S5
Citation: Giulio Perrotta, Narcissism and Psychopathological Profiles: Definitions, Clinical Contexts, Neurobiological Aspects and
Clinical Treatments. J Clin Cases Rep 4(S5): 12-25.
2582-0435/© 2021 The Authors. Published by TRIDHA Scholars.
12
Narcissism and Psychopathological Profiles: Definitions, Clinical Contexts,
Neurobiological Aspects and Clinical Treatments
Giulio Perrotta
Indepnedent Researcher, Italy
Correspondence should be addressed to Giulio Perrotta, info@giulioperrotta.com
Received: September 15, 2020; Accepted: September 27, 2020; Published: October 04, 2020
Doi: https://doi.org/10.46619/joccr.2021.S5-1003
ABSTRACT
Starting from the general concept of "narcissism", the present work focuses on the essential aspects of personality disorder
that define the clinical and diagnostic contexts, laying the foundations for a correct differential diagnosis, without neglecting
the neural characteristics developed by the scientific community. A new classification of the narcissistic disorder is
presented that better defines the different types, in a more general framework of the "narcissistic spectrum". The discussion
ends with the best suggested therapeutic approaches.
KEYWORDS
Narcissism; Personality disorder; Narcissistic disorder
INTRODUCTION
Narcissism: General Profiles and Definitions
In common parlance, the use of the term "Narcissism"
essentially takes on a negative meaning, identifying with
it an egocentric, selfish, vain, and conceited person, in all
its possible uses and socio-cultural contexts. In short,
narcissism is the tendency and psychological attitude of
those who make of themselves, of their person, of their
physical and intellectual qualities, the exclusive and pre-
eminent center of their interest and the object of a smug
admiration, while remaining more or less indifferent to
others, whose value and works they ignore or despise. In
technical language, in psychology and psychiatry, on the
other hand, the generally accepted meaning has a dual
value, depending on the context and other specific
indicators; in fact: in psychology, a distinction is made
between the functional form (healthy self-love, i.e.
normal love for oneself) and the dysfunctional form (the
insane egocentricity caused by a disorder of the sense of
self that is reflected in relationships with oneself and with
others); in psychiatry, on the other hand, it identifies the
foundation of the narcissistic personality disorder [1,2].
The origins of the term are Greek and come from the
myth of Narcissus. According to the story, Narcissus was
a handsome young man who rejected the love of the
nymph Echo. As punishment, he was therefore destined
to fall in love with his image, reflected in the water.
Unable to consummate his love, Narcissus thus turned his
gaze into the mirror of water, hour after hour, becoming
forever a flower (which bears his name, the narcissus).
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More recently, recalling the Greek concept of "self-love"
(hybris), in 1898, Havelock Ellis, an English sexologist,
used the term "narcissus-like" about excessive
masturbation, whereby the person becomes his sexual
object, while Paul Näcke, in 1899, was the first to use the
term "narcissism" in a study on sexual perversions,
giving it a purely clinical and psychological meaning. A
few years later, in 1911, Otto Rank published the first
psychoanalytic document specifically concerned with
narcissism, linking the latter to vanity and self-
admiration, before Sigmund Freud could pave the way
with his manuscript on narcissism in 1914, called
"Introduction to Narcissism" [3].
At the beginning of the first chapter, freud fully defines
narcissism as the "libidinal completion of the egoism of
man's drive for self-preservation", therefore not as a
perversion but as a character belonging in a different way
to all men and never completely overcome. According to
the Viennese doctor, the interest in the narcissistic stage
resides in the particular form of some psychosis in which
the ego of the sick person seems to be the center of the
libidinal current: The patient loses all interest in the
outside world by turning to himself his object libidinal
current, thus giving form to over-investment of the ego
which leads, for example, to delusions of grandeur. This
according to freud is what happens in paraphrenias
(schizophrenia and dementia præcox), despite obsessive
neurosis in which the interest towards the outside is
confirmed by the fantasies of the patient. Freud also
identifies this phase in the behavior of the child when he
assumes himself at the center of the world, in his
omnipotence of thoughts and the superstitious beliefs of
primitive men. In the second chapter, freud deals
extensively with the drives of the ego, the object libido,
and the libido of the ego, as opposed to Jung's theories
that tended to unify these drives into a single psychic
energy. Also in this chapter, freud exemplifies
narcissistic behavior in cases of human love life, illness,
and even hypochondria, when an "excited" organ
becomes somehow erogenous and susceptible to libidinal
investment. The dangers one encounters during the
narcissistic phase are, according to freud, anxiety due to
the complex of revascularization and some cases of
homosexuality, in which the beloved object still
represents an image of oneself. In the last chapter freud,
holding firm the distinction between object libido and
ego libido questions himself about the destiny of the
latter, going so far as to suppose that it goes to support an
idea that the ego has of itself. In adulthood, therefore, a
part of the narcissistic current is no longer directed to the
ego but to its ideal, an ideal to which freud acknowledges
the dignity of psychic instance and moral conscience.
The existence of this ideal would also be a condition for
the removal of drives and thoughts, as well as for
dreamlike censorship and the sensation of "feeling
observed" reported by neurotics. In the last part of the
book, the author follows the genesis of the ideal of the
ego, the dynamics of libidinal investments (especially in
love life), and underlines the importance of the ideal of
the ego in understanding the psychology of the masses.
Melanie Klein reinforces the concept of "primary
narcissism" (benign, typical of childhood) and
"secondary or protracted" (malignant, typical of
adolescence and adulthood), where the latter is the term
to indicate withdrawal to the ego. Heinz Kohut, the father
of the psychology of the self, also dealt with this theme,
defining the narcissistic state of the mind as a libidinal
investment of the self that has no pathological
characteristics but represents an organization that
expresses an attempt to deal with those irregular
maturing situations that inevitably occur in childhood
development, and that tends to idealize or counter-
idealize the parental imago. From this operation are born,
for Kohut, that love/hate and attraction/repulsion that
characterize the ideal of the ego, which has the task of
managing the world of drives, until a maturation and
balance that brings out a different stage of development
and promotes a careful reformulation of attitudes. The
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principle of Kouthian mythology is this "idealized
object" which contains its idealized images of the self
and the objects-self [2].
The dynamics can change considerably depending on the
type and degree of severity of narcissism, but in general,
there has been a tendency to replicate internalized
behavior as adults as children. It may happen, for
example, that a child neglected or mistreated by her
father, as an adult, seeks "deviant" companions, while a
child ignored or mistreated by her mother once an adult
may have controlled, and in the most serious cases,
stalking behaviors. Two types of narcissistic parents are
generally identified: a) disinterested: since the child does
not provide continuous feedback of confirmation and
flattery, the narcissistic parent loses interest in him,
ignores him, and neglects him, seeking satisfaction
elsewhere. However, if the child is successful (e.g. good
results at school), this becomes a sort of trophy that the
parent exhibits in public; b) controlling: he is obsessed
with the child, worries about him and for this reason,
monitors him continuously, asking him for continuous
feedback on his skills as a parent. He finds it very
difficult to respect its boundaries, even emotionally. He
cannot accept his child's autonomy and resorts to
psychological manipulation if he tries to escape his
control, e.g. by provoking a sense of guilt. Both types of
narcissistic parents have a low tolerance for failure and
can deny their child affection if he or she does not meet
their standards of perfection. At the same time, they may
compete with the child, who is urged to succeed "but not
too much" so as not to overshadow them. Growing up the
child can become a very successful person or self-
sabotage, or both. The narcissistic parent may have very
strong preferences. The preferred child is called "golden
child" by psychologists: it is the child with whom the
parent identifies and who collects, in his eyes, all his
virtues. The golden child is invested with great
expectations regarding his fulfillment, which serves to
give prestige to the parent. The unwanted child, on the
other hand, is called the "scapegoat": He is the child on
whom the narcissistic parent projects all his defects, who
does not make the right one and who seems predestined
to be a total failure. While the golden child is surrounded
by attention, on the scapegoat child the narcissistic parent
can exercise different forms of psychological or even
physical violence. In the most dysfunctional families, the
parent can incite the golden child to mistreat the
scapegoat child, who assumes the role of "black sheep"
of the family. It can also happen that the child rebels
against the expectations of the parent and for this reason
pass from the status of the golden child to that of the
scapegoat. It is no coincidence that a person who has
been raised by one or two narcissistic parents typically
displays the following characteristics: The habit of self-
criticism all the time; chronic fear of being disturbed,
difficulty in putting stakes on what others can afford with
her, tendency to deny one's own emotional needs; an
insecure attachment style, which translates into
generalized anxiety, emotional detachment, or an attempt
to be accepted by adapting one's personality to the
standards required by the parent; may have one or more
episodes that specialists call "need-panic" in which
suddenly the way one's needs were repressed no longer
works, and the person "explodes"; An extreme need for
independence, to be understood as a form of avoiding
relationships. Other characteristic traits are pervasive
anxiety and symptoms of post-traumatic stress disorder,
perfectionism, tendency to depression, a poor ability to
regulate emotions, possible eating disorders or substance
abuse, and above all a poor sense of personal identity [4-
7].
In more recent times, however, space has been given to
the clear distinction between the various forms of
narcissism [2,6,7].
1) The first form (also called “zero form”) is the "healthy
and functional" one consisting of self-love and healthy
selfishness (that which does not feed on the unhappiness
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of others). It is a condition of balance between the person
and the surrounding environment where the former is
perfectly aware of his means and does not diminish his
value due to problems of low self-esteem, guilt, or
unjustified shame or character insecurity.
2) The second form (or I form) is the "benign (or
apparent) and slightly dysfunctional" one. It consists of
the representation of oneself towards the surrounding
environment with a slight artifact of one's own identity,
where weaknesses and insecurities are masked with
attitudes of hyper security, exteriorization of positive
elements, and intellectualization. The excess of security
that others perceive is an apparent representation of the
person who uses his or her resources in a constructive
and non-destructive way, being positive for himself or
herself and others. In this subject, there are excellent
qualities of empathy and is not fed by the suffering or
failure of others.
3) The third form (or II form) is "oriented (or hidden) and
moderately dysfunctional". The person presents a
psychopathological picture already interesting from a
clinical point of view, showing one or more typical
features of narcissistic functioning: an evident
concentration on oneself in interpersonal exchanges; a
lack of awareness and recognition of one's psychological
traits (significant egosyntony); difficulties with empathy;
problems in distinguishing oneself from others;
vulnerability to shame or guilt; haughty body language;
flattery towards people who admire and strengthen it;
hating those who do not admire it; using other people
without considering the price of doing so; pretending to
be more important than they are; bragging (subtly but
insistently) about their achievements and exaggerating
them; claiming to be an "expert" in many things; inability
to see the world from others; denial of remorse and
gratitude. The excess of security and egocentricity that
others perceive is the product of the hypertrophic ego,
where the person destructively uses his resources
(concerning the environment), resulting in both positive
and negative for others. In this subject, there are scarce
qualities of empathy and is fed by the failure of others.
4) The fourth form (or III form) is the "dysfunctional (or
marked) and pathological" one, inserted in the DSM-V
manual of psychopathological disorders under the
heading "narcissistic personality disorder". It does not
have a genetic but environmental (and therefore family)
matrix, able to affect the personality structure of the
person from the early stages of growth (starting from the
so-called "narcissistic wound", generally associated with
a sense of shame). Typically, children who later become
narcissistic life in a family where their feelings and
interests are ignored, humiliated or repressed, unless they
can perform some "performance" capable of filling the
parent with pride; they become "hungry" for recognition
and praise, begin to conceive human relationships
essentially as based on power and control, and can begin
to use seductive and manipulative techniques. The
hypothesis of the fundamental role in the development of
the narcissism of resentment seems to emerge more and
more strongly, that is, that feeling of having suffered
injustice and not being able to rebel against it. If the child
feels that he or she has experienced strong injustices, he
or she can develop resentment as a defense system, and
thus reach adulthood with certain expectations of what he
or she is entitled to as compensation. In turn, the fourth
form has four levels of severity (mild, moderate, severe,
and very severe) and two organizational types
(covert/overt).
In emotional and sentimental relationships, especially the
narcissist described in the third and fourth form, easily
establishes a "toxic relationship", creating a relational
dependence necessary to feed his need for admiration: In
the first phase we find the classic attitude of "love
bombing", where the person is studded with messages
and filled with love and attention, then we move on to the
colder and more sterile phase of "gaslighting" and finally
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abandonment. Only at this moment, the victim of these
behaviors becomes even more attached to the person,
becoming emotionally dependent. It must be said,
however, that the "dependent" person always presents a
series of traits or a real personality disorder (tendentially
narcissistic, borderline, or dependent) [1,7].
Narcissistic Personality Disorder and Clinical Contexts
As already mentioned above, the fourth form represents
the most serious clinical hypothesis: Narcissistic
personality disorder. By definition, it is a personality
disorder whose main symptoms are pathological
egocentricity, a deficit in the ability to feel empathy
towards other individuals, and the need to perceive
admiration, which begins in early adulthood and is
present in various contexts [2]. The notion of narcissistic
personality disorder was formulated by Heinz Kohut in
1971 and introduced at his suggestion in the diagnostic
and statistical manual of mental disorders (DSM). The
clinical picture it describes is a particular form of
narcissistic disorder. What distinguishes these patients,
i.e. the psychological structure hypothesized by Kohut,
and for which he coined the term "grandiose self", is a
sort of so-called "false self" or "false self", which
preserves some of the primitive characteristics of the
infantile self, an overly idealized and "omnipotent" inner
image that the individual perceives as the true "I".
Patients with narcissistic personality disorder
overestimate their abilities and exaggerate their
successes. They think they are superior, unique, or
special. Their overestimation of their value and
achievements often implies an underestimation of the
value and achievements of others. These patients are
preoccupied with fantasies of great success, of being
admired for their overwhelming intelligence or beauty, of
having prestige and influence, or of feeling great love.
They feel that they should only socialize with other
people as special and talented as themselves, not with
ordinary people. This association with extraordinary
people is used to support and improve their self-esteem.
Because patients with narcissistic disorders need to be
admired, their self-esteem depends on the positive
consideration of others and is therefore usually very
fragile. People with this disorder often look to see what
others think of them and assess how well they are doing.
They are sensitive and annoyed by other people's
criticism and failure, which makes them feel humiliated
and defeated. They may respond with anger or contempt,
or they may brutally fight back. Or they can withdraw or
accept the situation externally, in an attempt to protect
their sense of self-importance (grandiosity). They can
avoid situations in which they may fail. The traits and
manifestations that describe this disorder are multiple and
give rise to a complex casuistry of personalities, with
variable characteristics, located in a very broad spectrum
of type and severity. When subjected to criticism,
individuals with narcissism can generally react with
anger, outrage, or insolence. This can sometimes lead to
a form of social withdrawal that can hide a sense of
grandiosity. Interpersonal relationships are typically
short-lived and short-lived due to the inability of the
narcissist to perceive the emotions of the person in front
of them and thus offend the sensibilities of others. This
pattern of behavior can also lead to high results, thanks to
insensitivity to criticism and security, but intolerance to
criticism and the constant need to feel admired can lead
to failure. This can be associated with the development of
a depressed mood, social withdrawal, and persistent
dysthymia, or major depressive disorder. Conversely,
long periods of grandiose feelings can be associated with
hypomaniacal mood development [8,9].
In summary, the psychological characteristics of
individuals with narcissistic personality disorder are [2]:
a) "Vision of themselves": They consider themselves to
be defective, vulnerable to abuse, betrayal, neglect. "I'm
bad", "I don't know who I am", "I'm weak and I feel
overwhelmed", "I can't help myself";
b) "Vision of others": They can see others as warm and
loving but still consider them unreliable because "they
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are strong and could be supportive, but after a while
change to hurt or abandon me";
c) "Intermediate and deep beliefs": "I have to ask for
what I need", "I have to answer when I feel attacked", "I
have to do it because I have to feel better", "if I am alone,
I won't be able to face the situation", "if I trust someone,
they will sooner or later abandon me or abuse me and I
will feel bad", "if my feelings are ignored or neglected, I
will lose control";
d) "Coping strategies": Submitting, alternating inhibition
with dramatic protest, punishing others, expelling tension
with self-harm.
The clinical diagnosis according to the DSM-V requires
that there should be a persistent pattern of grandiosity,
need for flattery and lack of empathy, with the presence
of five or more of the following elements: An
exaggerated, unfounded sense of one's importance and
talents (grandiosity), concern with fantasies of unlimited
success, influence, power, intelligence, beauty, or perfect
love; a belief that one is special and unique and should
only associate with people of the highest level; a need to
be unconditionally admired; a feeling of privilege;
exploitation of others to achieve one's goals; lack of
empathy; envy of others and belief that others envy them;
arrogance and pride. The more elements are present, the
more serious will be the pervasiveness of the
psychopathological condition [2,8].
The pathological (or malignant) narcissist, however, can
have two different ways to represent himself: the
"covert" form and the "overt" form. The covert narcissist
is inhibited, vulnerable, hypersensitive to criticism, afraid
of rejection, often feels shame and embarrassment, and
always feels a huge distance between himself and others.
But, unlike what can be seen on a superficial observation,
the covert narcissist is not a sweet, affectionate, and
defended feline but a sleeping lion. He shares with his
overt counterpoint the attitude of exploitation and
manipulation towards others, the absence of empathy, a
certain amount of aggressiveness (although generally
lower than the narcissist overt) and the presence of
grandiose fantasies (although these, unlike what happens
for the narcissist overt, are hidden and less aware). The
fear of failing and not realizing their fantasies of
greatness often determines in these people the tendency
to avoid situations in which they may be the center of
attention. Covert narcissists often feel shame and anger, a
sense of failure and defeat, rejection, expulsion. The
overt narcissist instead appears superior, self-sufficient,
dominant, euphoric, triumphant (or cold and detached).
He feels he does not belong to the rest of humanity or a
superior elite [9].
For this reason, it seems more correct to speak of the
"narcissistic spectrum" and not of simple narcissism. A
continuum that goes from healthy to malignant
narcissism, passing through covert and overt forms,
depending on the degree of grandiosity, loss of contact
with reality, lack of feelings and contact with one's own
needs, body sensations and emotions. And narcissists
place themselves at a point on this continuum [2].
The pathological (or malignant) narcissist (fourth form or
“III form”), anyway, essentially depends on "level of
insight" concerning the external (reality and
environment) and internal (the relationship between the
deep instances) plan and consequently also the
psychological treatment will have to adapt to the clinical
form suffered. Normally, this form is distinguished in
four levels of severity (mild, moderate, severe, and very
severe) and two organizational types (covert/overt); the
writer, however, prefers to use a new classification, more
functional and structured [10].
Overt Model
Excellent level of insight
Narcissistic patients of this level define themselves as
"oriented" because they meet the criteria proposed by
DSM-V, within a framework of a persistent and
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pervasive model of grandeur, need for flattery, and lack
of empathy, but in a strictly essential way (5 criteria out
of 9, mainly related to the envy of others and the belief
that others envy him, lack of empathy, a feeling of
privilege, concerns related to fantasies of success or
perfection and need for admiration), still managing to fit
well into the environmental, family and work context,
building a network contacts able to allow him an
excellent adaptation with the outside.
Good level of insight
Narcissistic patients of this level define themselves as
"precarious" because they meet the criteria proposed by
DSM-V, within a framework of a persistent and
pervasive model of grandeur, need for flattery, and lack
of empathy, but in a strictly essential way (6 criteria out
of 9, mainly related to the envy of others and the belief
that others envy him, lack of empathy, a feeling of
privilege, concerns related to fantasies of success or
perfection, need for admiration and feeling of privilege),
managing to fit into the environmental, family and work
context, but building a fragile and insecure network of
contacts, which tends to disintegrate following the
aforementioned behaviors.
Mediocre level of insight
Narcissistic patients of this level define themselves as
"sensitive" because they meet the criteria proposed by
DSM-V, within a framework of a persistent and
pervasive model of grandeur, need for flattery, and lack
of empathy, but in a strictly essential way (7 out of 9
criteria, mainly related to the envy of others and the
belief that others envy him, lack of empathy, a feeling of
privilege, concerns related to fantasies of success or
perfection, need for admiration, feeling of privilege,
arrogance, and presumption), managing to barely fit into
the environmental, family and work context and building
a fragmented and disorganized network of contacts,
which tends to distance them as soon as behavioral
manifestations become pressing and embarrassing. In
some cases there are also paranoid and/or dissociative
thoughts of a minor or temporary nature.
Low level of insight
Narcissistic patients of this level define themselves as
"vulnerable" because they meet the criteria proposed by
DSM-V, within a marked of a persistent and pervasive
model of grandeur, need for flattery, and lack of
empathy, but in a strictly essential way (8 criteria out of
9, mainly related to the envy of others and the belief that
others envy him, lack of empathy, a lack of privilege,
concerns related to fantasies of success or perfection,
need for admiration, feeling of privilege, arrogance and
presumption, and beliefs of being special, unique or very
high profile), failing to fit into the environmental, family
and work context, failing to build a network of contacts
stable over time, if not with occasional, sporadic and
superficial relationships. In some cases there are also
paranoid and/or dissociative thoughts of moderate entity
or in any case temporary.
Bad level of insight
Narcissistic patients of this level define themselves as
"critical" because they meet the criteria proposed by
DSM-V, within extremely marked of a persistent and
pervasive model of grandeur, need for flattery, and lack
of empathy, but in a strictly essential way (9 out of 9
criteria, mainly related to the envy of others and the
belief that others envy him, lack of empathy, a lack of
privilege, concerns related to fantasies of success or
perfection, need for admiration, feeling of privilege,
arrogance and presumption, and beliefs of being special,
unique or of the highest-profile, excessive grandiosity
and the need to exploit others to achieve their goals and
objectives), failing to fit into the environmental, family
and work context and failing to build a network of
contacts, even essential or minimal.
Covert Model
Excellent level of insight
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Narcissistic patients of this level define themselves as
"oriented" because their typology is not clearly defined in
the criteria of the DSM-V, but is nevertheless part of a
persistent and pervasive model of personalities in a
general picture of lack of empathy, selfishness, need to
draw attention to their suffering and needs, presenting the
following characteristics: deresponsibility with
attribution of blame or not to others, operational
overcontrol, irrational fixations/beliefs/obsessive
episodes, an exaggerated and unfounded underestimation
of one's skills and qualities, although aware of the results
or objective findings and need to draw attention to one's
own needs and requirements, even with the use of
complaining and/or guilt. Still managing to fit well into
the environmental, family and work context, building a
network contacts able to allow him an excellent
adaptation with the outside.
Good level of insight
Narcissistic patients of this level define themselves as
"oriented" because their typology is not clearly defined in
the criteria of the DSM-V, but is nevertheless part of a
persistent and pervasive model of personalities in a
general picture of lack of empathy, selfishness, need to
draw attention to their suffering and needs, presenting the
following characteristics: deresponsibility with
attribution of blame or not to others, operational
overcontrol, irrational fixations/beliefs/obsessive
episodes, an exaggerated and unfounded underestimation
of one's skills and qualities, although aware of the results
or objective findings and need to draw attention to one's
own needs and requirements, even with the use of
complaining and/or guilt and psychosomatic illnesses of
mild to medium magnitude. He manages to fit into the
environmental, family and work context, but builds a
fragile and insecure network of contacts, which tends to
disintegrate as a result of the above behaviors.
Mediocre level of insight
Narcissistic patients of this level define themselves as
"oriented" because their typology is not clearly defined in
the criteria of the DSM-V, but is nevertheless part of a
persistent and pervasive model of personalities in a
general picture of lack of empathy, selfishness, need to
draw attention to their suffering and needs, presenting the
following characteristics: deresponsibility with
attribution of blame or not to others, operational
overcontrol, irrational fixations/beliefs/obsessive
episodes, an exaggerated and unfounded underestimation
of one's skills and qualities, although aware of the results
or objective findings and need to draw attention to one's
own needs and requirements, even with the use of
complaining and/or guilt, psychosomatic illnesses of mild
to medium magnitude and episodes of generalized or
social anxiety, which become involuntary simulations of
panic attacks or hysterical crises. He manages to barely
fit into the environmental, family, and work context and
building a fragmented and disorganized network of
contacts, which tends to distance them as soon as
behavioral manifestations become pressing and
embarrassing. In some cases there are also paranoid
and/or dissociative thoughts of a minor or temporary
nature.
Low level of insight
Narcissistic patients of this level define themselves as
"oriented" because their typology is not clearly defined in
the criteria of the DSM-V, but is nevertheless part of a
persistent and pervasive model of personalities in a
general picture of lack of empathy, selfishness, need to
draw attention to their suffering and needs, presenting the
following characteristics: Deresponsibility with
attribution of blame or not to others, operational
overcontrol, irrational fixations/beliefs/obsessive
episodes, an exaggerated and unfounded underestimation
of one's own skills and qualities, although aware of the
results or objective findings and need to draw attention to
one's own needs and requirements, even with the use of
complaining and/or guilt, psychosomatic illnesses of mild
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to medium magnitude, episodes of generalized or social
anxiety, which become involuntary simulations of panic
attacks or hysterical crises and lack of empathy or
repressed or dysfunctional affectivity. He is unable to fit
into the environmental, family, and work context, failing
to build a stable network of contacts over time, except
with occasional, sporadic and superficial relationships. In
some cases there are also paranoid and/or dissociative
thoughts of moderate or temporary entity.
Bad level of insight
Narcissistic patients of this level define themselves as
"oriented" because their typology is not clearly defined in
the criteria of the DSM-V, but is nevertheless part of a
persistent and pervasive model of personalities in a
general picture of lack of empathy, selfishness, need to
draw attention to their suffering and needs, presenting the
following characteristics: deresponsibility with
attribution of blame or not to others, operational
overcontrol, irrational fixations/beliefs/obsessive
episodes, an exaggerated and unfounded underestimation
of one's own skills and qualities, although aware of the
results or objective findings and need to draw attention to
one's own needs and requirements, even with the use of
complaining and/or guilt, psychosomatic illnesses of mild
to medium magnitude, episodes of generalized or social
anxiety, which become involuntary simulations of panic
attacks or hysterical crises, lack of empathy that can go
as far as anaffectiveness and/or insensitivity to the
suffering of others, with exploitation of others to obtain
attention and visibility with respect to one's own needs.
He fails to fit into the environmental, family, and work
environment and fails to build or maintain a network of
contacts, even essential or minimal ones.
Narcissistic personality disorder is often also associated
with forms of eating disorders such as anorexia nervosa
or substance use disorders. Histrionic personality
disorder, borderline, antisocial, and paranoid disorders
can also be associated with this disorder. In the diagnosis
of comorbidity, particular attention should be paid to a
potential substance use disorder, which may develop in
the association, and to a diagnosis of maniacally or
hypomaniacally: These episodes may present peaks of
grandiosity and self-esteem similar to those present in a
narcissistic disorder. It should be clearly distinguished
from: a) “bipolar disorder”, as patients with narcissistic
personality disorder often present with depression and,
due to their grandiosity, may be misdiagnosed as bipolar.
Such patients may suffer from depression, but their
persistent need to rise above others distinguishes them
from those with bipolar disorder. Moreover, in
narcissistic personality disorder, mood changes are
triggered by insults to self-esteem; b) “antisocial
personality disorder”, as the exploitation of others to
promote themselves is characteristic of both personality
disorders but the reasons are different. Patients with
antisocial personality disorder exploit others for material
gain; those with narcissistic personality disorder exploit
others to maintain their self-esteem; c) “histrionic
personality disorder”, because the pursuit of attention by
others is characteristic of both personality disorders, but
patients with narcissistic personality disorder, unlike
those with histrionic personality disorder, act in contempt
of anything nice and silly to attract attention; they want
to be admired [11-26].
Epistemological Data, Etiological Causes and
Neurobiological Basis of the Psychopathological
Disorder
According to recent data, a narcissistic personality
disorder can be diagnosed in about 1% - 4% of the adult
population, while in hospitalized patients it can be as
high as 15% - 20%. The spread of this pathology does
not seem ubiquitous, but strongly influenced by cultural
contexts: It seems to be more widespread almost
exclusively in capitalist and western countries. The
disorder seems to have a sexual or gender component so
that the spread is not equal between the two sexes: Males
affected are more numerous than females, by a share
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Current Trends in Clinical & Medical Reports
21
between 50% and 75%. While females tend to be more
affected by borderline personality disorders, which share
some characteristics similar to narcissistic ones, such as a
substantially unstable mode of relationship. Some
narcissistic traits then appear during the development of
the individual and to a certain degree are normal. These
character traits are very common among adolescents,
without necessarily resulting in a pathological personality
in adulthood [11].
Although some studies mention the importance of genetic
influence on the development of this disorder (especially
about the search for attention, the need to be flattered and
grandiosity), all the other studies suggest that, in the
development of narcissistic personality disorder, the
interaction that develops between the parent and the child
occupies a place of primary importance; in particular,
subjects presenting this disorder seem to have developed,
starting from the relationship with their parents,
relationships characterized mainly by a representation of
themselves as in need of care and by a representation of
other people as unwilling to provide it, therefore by the
expectation of being rejected. This condition generates in
the subject a tendency to organize one's existence without
the love of others and not requiring their support, relying
only on oneself and aiming at absolute self-sufficiency,
not recognizing and not expressing one's needs, assuming
attitudes of detachment and superiority. From these
premises, intimacy becomes a threatening territory in
terms of rejection, so that the individual soon learns to
renounce it by devaluing it. At the same time, since the
figure of attachment is perceived as distant and
inaccessible, not manifesting the need for it appears as
the best way to be able to gain a certain amount of
closeness to it; together with this, the subject develops,
on the one hand, the tendency to dissociate aspects of
himself perceived as negative (desires and fragility) as
they expose him to the further risk of being rejected, on
the other hand, the tendency to assume attitudes that
make him as lovable as possible in the eyes of the figure
of attachment itself. At this point, the subject elaborates
the conviction that proximity to the other must be
imposed or extorted through a tight control, thus aiming
at possessing the other, rather than being with him, in the
certainty that the latter would never accept him, being
able to choose him. Parallel to this, within a relationship
in which the subject has the impression that the other is
not there (either because he is absent, distant,
disinterested or because he is physically present, but
unable to listen to his needs), he gets used to considering
his world of meanings as the only one existing; in this
sense, also the invalidations coming from outside are
filtered and not taken into consideration so that the
subject develops the tendency to a grandiose
representation of himself, the expectation of having to
receive by right special treatments, the disposition to
aggressive attitudes towards an environment that does not
meet his expectations. The observations on early child-
parent interactions also suggest the presence of a style of
care in which the child is considered by the parent as a
"means" through which to develop and enhance self-
esteem, without ever being appreciated for his or her
abilities and merits. Although the family environment of
the subject with a narcissistic personality disorder may
appear welcoming towards the latter the parental figures
are generally devoid of empathy, emotionally cold and
detached, profoundly incapable of satisfying their child's
needs; in this sense, it frequently occurs that they
attribute roles or functions to their children that are
inappropriate compared to their normal evolutionary
processes. In such circumstances, emotional deprivation
on the part of parental figures seems to be at the basis of
the angry attitude that most often individuals with
narcissistic personality disorder tend to assume in the
relational sphere. It also seems relevant to come from a
family considered by most of the community as different
based on ethnic, racial, geographical or economic status
reasons. In such situations, the concept of self is
characterized by feelings of inadequacy and inferiority,
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envy, refuge in idealized fantasies, or attachment to
people of prestige. The families of narcissists are
frequently isolated from a social point of view, so the
future narcissist, not developing the ability to recognize
commonality and belonging to the group, solves the
threat to self-esteem by clinging to the sense of
superiority and believing to be "excluded because
envied" [7,11,26].
The American doctor Alexander Lowen, founder of the
school known as bioenergetics but of psychoanalytic
school, is the best known among the first authors to
dedicate monographic studies to pathological narcissism.
He proposes a typing of the narcissistic personality
disorder according to a scale, identifying some degrees,
considered as having increasing gravity: the "phallic-
narcissistic character", defined by Lowen as the least
serious degree, followed by the "narcissistic character",
then by what Lowen calls the borderline personality, the
"psychopathic personality" and finally the "paranoid
personality". This scale would correspond to an increase
in the areas in which the personality is dysfunctional, a
progressive loss of realism and increasing forms of
grandeur, a progressive deficit in the ability to feel
empathy for others as well as to perceive the authenticity
of one's feelings [27].
From a cognitivist point of view, the heart of
psychopathology lies in the processing of information
that is altered due to dysfunctional beliefs, and thus leads
to specific behavioral and emotional experiences; these
structures, called "patterns", are like lenses through
which we read what happens to us and get ideas about
ourselves, others and the world. Patterns, according to
Beck, develop during childhood through the interaction
between predisposing biological factors and relationships
with significant figures. When the child's primary needs
are frustrated, specific "early maladaptive patterns" are
configured, which in the case of narcissistic disorder
concern emotional deprivation (feeling that one's
emotional needs will never be satisfied in the relationship
with others), sense of inadequacy and shame (the belief
that one is wrong, inferior, and cannot be loved if the
other discovers these weaknesses) and pretensions
(tendency to feel superior to others, to compete for
dominance and to think that one deserves special rights
or privileges). The family context within which these
patterns are formed would be characterized by loneliness
and isolation, lack of rules and excessive permissiveness,
exploitation or manipulation (for example, the child has
been a tool to meet the needs of the parents) and
conditional approval, i.e. the possibility of feeling special
and loved only when the parents' standards are met. A
particular attention to thought processes also
characterizes the interpersonal metacognitive approach,
which, although in line with the cognitive-behavioral
model, adds to it significant aspects that we could define
as over-ordered. In this model, the architecture of
personality disorder is more complex and identifies as a
central factor the compromise of metacognitive
functions, i.e. the set of abilities that allow us to access
our internal states and to grasp those of others. This set of
functions is essential for the development of the Self and
the construction of healthy interpersonal relationships,
and it is for this reason that these aspects are strongly
compromised in personality disorders [28].
Knowledge about the neurobiological functioning of the
narcissist's mind is very limited, despite the high clinical
relevance of the disorder and the tendency to
underestimate its prevalence. In recent years, however,
there has been an increase in contributions that deepen
the black-biological functioning of the narcissist brain,
intending to also give a neurobiological explanation of
the cognitive, emotional, and behavioral aspects that
characterize the functioning of these patients. In a pilot
study in 2015, some authors analyzed the gray and white
matter of six male patients with narcissistic personality
disorder (NPD), comparing them with a control group of
subjects without personality disorder. The results show
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that patients with NPD show alterations in gray matter
including anterior cingulate cortex, right prefrontal
cortex, and bilateral medial prefrontal cortex. The
evidence found in the frontal lobes provides a basis for
hypothesizing an alteration in the structural connection of
the prefrontal and subcortical areas. The latter include the
cluster below the right lateral prefrontal cortex, such as
the right anterior thalamic peduncle, the front-thalamic
tract connecting the medial thalamic nuclei with the
medial and lateral prefrontal cortex. This suggests that
alterations in the white matter may contribute to
structural cortical deficits. The results need to be
replicated due to the small sample size, but a potential
malfunction in the frontothalamic or front-limbic systems
in patients with NDP could be hypothesized, as it has
been found in other B-cluster disorders. A recent
functional MRI study supports the hypothesis of the
presence of a right lateral prefrontal anomaly associated
with narcissism; in a non-clinical sample of subjects with
the prevalence of narcissistic traits, there is a decrease in
the activation of the right anterior insula and right
dorsolateral prefrontal cortex. Given the scarcity of this
type of research on NPD, the data of this study serve as a
starting point for the development of a neurobiological
model of the disorder that can take into account its
different phenomenological manifestations. It can now be
said that it is plausible that this structural prefrontal
deficit may contribute to emotional dysregulation,
cognitive deficits related to the attribution of
responsibility, or coping strategies, which are some
central aspects of the psychopathology of the disorder
[10,11].
Clinical Treatments
The general treatment of narcissistic personality disorder
is the same as for all personality disorders.
Psychodynamic psychotherapy, which focuses on the
underlying conflicts but can be scarcely effective if the
form is particularly severe, as there is little scope for
focused transference analysis and mentalization
techniques. Cognitive-behavioral therapy can be
beneficial to these patients, as the therapist can leverage
the personality characteristics of the subject and model
their behavior, as long as the patient is collaborative.
After a first series of evaluation meetings, the therapist
returns the case showing the patient the personal mental
functioning (thoughts, emotions, behaviors) and therefore
the thoughts and behaviors that generate suffering. The
aim, first of all, is to replace such negative automatic
thoughts with more adaptive and realistic ones using the
technique of cognitive restructuring. A typical work is
that on "all or nothing thinking" which consists in the
tendency of narcissists to consider themselves either
wonderfully superior or completely worthless. The
restructuring of this form of thought does not question
the value of narcissism but helps it to limit the excessive
expectations it has about itself and others and to replace
them with more realistic alternative beliefs such as: "One
can be human, like everyone else, and still be unique"; "I
can be happy to be like others, rather than always having
to be the exception"; "Common things can be very
pleasant". The same process of identification and
substitution applies to dysfunctional behaviors, such as
possible acting out of anger, characteristic of the
disorder. To the purely cognitive therapy, it is necessary,
afterward, to combine behavioral techniques and specific
strategies to improve social skills such as the ability to
manage anger, to enter into intimacy with the other, the
expression of one's own needs without the need to use
manipulation and empathy and therefore the ability to
recognize the value and importance of the needs and
feelings of others. Also the Schema Therapy, or more
precisely Schema-Focused Therapy, as an integrated
approach that combines aspects of cognitive-behavioral,
experiential, interpersonal and psychoanalytic therapy in
a single model of intervention, is very useful, to unravel
toxic patterns or traps. Evidence in favor of drug therapy
for the treatment of narcissistic personality disorder is
rather scarce, except in cases where it is used for the
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24
treatment of states of social anxiety, hypochondria,
depression, states of angry impotence that most often
motivate the request for help. Pharmacological therapy
does not intervene on personality characteristics, but it
can still be very useful for the treatment of possible
secondary consequences. In particular, the drugs that can
effectively act on the psychopathological phenomena
frequently associated with narcissistic personality
disorder are selective serotonin reuptake inhibitors
(SSRIs), anticonvulsant drugs, and mood stabilizers
[22,26,28].
CONCLUSION
Narcissistic personality disorder, together with borderline
disorder and the large family of cluster A disorders are
probably the most difficult therapeutic challenges to
overcome, both because of the patient's lack of complete
cooperation and their pervasiveness. If, on the one hand,
genetics offers food for thought on trends towards
grandiosity and the need for gratification, on the other
hand, the socio-environmental and family condition plays
a fundamental role in the genesis of this disorder, which
certainly appears not as a unitary one but in the form of a
"narcissistic spectrum", with a precise gradation and
scale. From the healthy form of narcissism (zero form),
we move on to the more dysfunctional and complex
forms: Type I (benign), type II (oriented), type III
(pathological, in its two forms "covert" and "overt"),
further distinguishing five other forms by type. The best
approach is undoubtedly the integrated one
(psychotherapy and psychopharmacology), where patient
awareness plays a fundamental role between cognitive-
behavioral, strategic and dynamic techniques and
strategies.
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