Narcissistic Personality Disorder: Illness or Character Flaw?

I've seen a lot of posts on the Narcissist Personality Disorder on my Google Reader recently. However, I've notice that most of them are not going off of recent research. The information in this paper is two years old. It is not the final format, but all the material is here.

Narcissistic Personality Disorder: Illness or Character Flaw?

Written by Amanda D. Barncord Doerr

CHAPTER 1. INTRODUCTION

Initial shock

Walking out of a therapist's office after being told that their loved one is exhibiting the symptoms of a Narcissistic Personality Disorder (NPD), a person is forced to consider the implications of this diagnosis. There is confusion about how this diagnosis affects their view of their loved one, whether the NPD should be pitied or scorned. There is curiosity about the disorder itself and the affect, if any, it would have on the self view of the one diagnosed. And then there are worries about what the diagnosis means to the therapist treating the loved one and what is the prevailing thought on the Narcissistic Personality Disorder among mental health professionals.

Two views

In the literature available to the general public, there can be found two very diverse views of the Narcissistic Personality Disorder. The more accessible sources appear to portray the disorder as a character flaw or a label for difficult people. Popular author and psychiatrist, M. Scott Peck (1983) said in his book People of the Lie: The Hope for Healing Human Evil that evil people could appropriately be classified as a variant of the narcissistic personality disorder. On a website that approaches the disorder from a layperson's perspective, Joanna Ashmun (2004) points out that in the clinical literature NPD is usually discussed as a "character disorder".

On the other hand, the inclusion of Narcissistic Personality Disorder into the DSM, would strongly suggest to many people that it is an illness. Indeed many online "psychology" sites call it just that. Though to some laypeople it is more likely to suggest that the psychology field is trying to explain away a set of character flaws by suggesting that the "sufferer" is not responsible for their actions. Of course, the laypeople who cling to this notion of irresponsibility in the mental health field rarely believe in the need to view the sets of behavior that comprise an NPD in an objective and scientific manner.

Self-proclaimed NPD sufferer and author of Malignant Self Love : Narcissism Revisited, Sam Vaknin (1997) confuses the matter further with his views on whether or not narcissistic personality disorder sufferers can help themselves on his website. He first convinces the reader that a narcissist cannot help themselves and then goes on to show that the essential ingredients to remission is for the narcissist to be humble and take responsibility for his own actions.

Professional questions

All of this leads to the following questions. What is the professional view of the Narcissistic Personality Disorder? What data supports this view? Does treating NPD as a illness give any relief to the life impairment caused by it? What are the alternatives for narcissistic personality disorder sufferer and those who must interact with them?

CHAPTER 2. DIAGNOSIS

Background and history

Narcissism may be one of the most commonly recognised character flaws. The word itself comes from the Greek myth of Narcissus, a young man who fell in love with his own image in a pool and then was turned into a daffodil by the gods for punishment for his hubris. Ellis and Nacke first introduced the term into psychiatry at the end of the 1800s, but it took Freud and Rank in the 1910s to describe the disorder. Reich an Horney expanded on the concept some in the 1930s. Then for about 40 years the issue laid practically dormant until the 1970s, when Kohut and Kernberg connected the developmental processes of self to the formation of pathological narcissism. It was their work that introduced the Narcissistic Personality Disorder (NPD) into the DSM. (Rivas, 2001)

Symptomology

According to the research of Dimaggio, Semerari, Falcone, Nicolò, Carcione, & Procacci (2002, December), NPDs often display vague sensations of emptiness, boredom and emotional anesthesia. Their emotional state is not available to their consciousness. This cognitive deficit is a form of alexithymia. Alexithymia is the inability to link the physical response to words, fantasies, and feelings to the expression thereof. An example is when an NPD shows facial expressions of annoyance, but when asked about the annoyance, they will deny feeling anything and may even start looking confused when the questioner continues to probe the matter. This lack of self-awareness makes self-reflection very difficult for the NPD. To compensate, they rely on having a rigid set of values to help make decisions and judgments. However, unable to recognise the internal signals that guide most people when there is conflict between their beliefs and actions, NPDs will often act in counterproductive ways.

One side effect of the value system reliance is that NPDs usually display two main states of mind; admiration and contempt. The overt admiration state involves disdainful grandiosity, fantasies of wealth, power, physical attractiveness, and invulnerability. The covert contempt state involves an out-of-place sensitiveness, a sense of inferiority, insignificance and fragility, and a search for glory. It is usually during the therapeutic process that other states, such as anger, envy, fear and confusion are displayed.

The rigid value system also creates many interpersonal problems when compounded with other aspects of the disorder, such as a sense on entitlement and a haughty demeanor. Unable to reflect upon their own actions, NPDs also lack the ability to emphasize with others, seeing them instead as "self-objects". This deficit in object relations has been recognised in NPDs since the works of Kohut and Kernberg. When speaking to others, NPDs tend to be rhetorical, vague and evasive in their speech, with an egocentric view of reality. It has been noted that while NPDs transmit nonverbal signals, they do not receive them. And while they may not be able to reflect on their feelings, they can use them as an engine for social action.

Despite the NPD's belief that they should only associate with other special people, they are threatened by "kindred spirits" and will treat anyone who may be their equal as competition, instead of as a compatriot. The fragile self-esteem of the NPD does not allow for true peers. Nor does it allow for narcissistic damage in the form of insult or loss of esteem. Robert Simon (2002) noted that the actions caused by such damage resembled PTSD, without the flashbacks. This would include the outbursts of anger and other antisocial acts associated with narcissistic rage.

According to Phebe Cramer (1999), NPDs are more likely than other personality disorders to seduce their environment to meet their needs. When this fails, they will fall back on rationalization as a defense, resorting to fantasy and complete denial when that fails.

DSM criteria

For a patient to be diagnosed with having a narcissistic personality disorder, five of the following nine criteria must be met: a grandiose sense of self; a preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love; the belief that the patient is special and can only be understood by other special people; a need for excessive admiration; a strong sense of entitlement; a pattern of taking advantage of other people to met their own needs; a lack of empathy; a sense of envy towards others or the belief that others envy them; arrogant behavior. (APA, 2000)

Prevalence

According to the American Psychiatric Association (2000), the prevalence of NPD is less than 1% of the general population and 2 to 16% in the clinical population. In 1999, Rivas (2001) pointed out that the Narcissistic Personality Disorder was removed from the tenth revision of the International Statistical Classification of Diseases and Related Health Problems, leading some researchers to believe that maybe NPD was a cultural disorder, specifically an American one. However, studies supported by by the National Project of Mental Health of the Istituto Superiore di Sanità, Rome, Italy (Dimaggio et al, 2002), have since given a great deal of insight into this disorder.

CHAPTER 3. VALIDITY

Character disorder

It is not without good reason that researchers like Joanna Berg (1990) and others refer to NPD as a "character disorder". Some of the more noted aspects of this disorder is a high sensitivity to criticism, grandiosity, a sense of entitlement, a lack of empathy, envy and a need for excessive praise. All of these are considered character flaws in Western civilization. In fact, if we were to compare the traditional seven deadly sins with the criteria for NPD, we would be easily be able to match three - envy, pride and greed to the DSM-IV's list. Add narcissist rage to match with wrath, and we have over half the deadly sins. Compare the diagnostic criteria with any established religious code and one might begin to wonder why the NPD is seeing a therapist instead of a religious advisor. After all, Cramer (1999) said that the NPD does have a remnant of a moral conscience. Why is a deficiency of morals being addressed in in a manual for mental disorders in the first place?

The answer is quite simple. These people have behavioral problems that need to be treated and most of them do not have the ability to acknowledge their own faults. But still, it is interesting to note that Links & Stockwell (2002) found that some pathological narcissism can be cured through real life accomplishments. If able to achieve a major real life accomplishment, a NPD can be helped to reflect on their success. Once this reflection occurs, the NPD often ends up with a more realistic view of themselves and no longer needs to hold on to the fantasies of success, wealth and power they had been previously clinging to.

Another example of a successful treatment of NPD comes from Nicolò, Carcione, Semerari & Dimaggio (2007). It requires the therapist to time when they are caring towards the NPD to coincide when the NPD is willing to accept the idea that it is okay to be flawed. Then the therapist's help is seen as an enrichment, instead of an insinuation that the NPD is fatally flawed. In the case study given, the female NPD patient found acceptance for being helped through her own childhood memories of helping elderly strangers in a public restroom.

The two ways listed in this paper of affecting NPD in a positive way does reflect the adage that for a NPD to be cured, they must first learn humility. Then, as Sam Vaknin (1997) said, they must take responsibility for their actions. One cannot miss the fact that humility and responsibility are considered positive character traits in this culture, calling to mind the question again, should character flaws be grouped with mental disorders?

Cognitive deficits

But is NPD really a set of behaviors caused by a lack of moral fiber? Or the results of cognitive defects? The evidence of alexithymia, the inability to reflect on their own actions, not being able to receive conversational cues, and the disturbances in object relations all suggest that there is something going on inside the mind of the NPD that has nothing to do with moral turpitude. Stevens et al (1984) reported that NPDs felt a great deal of discomfort while experiencing considerable excitement. And what of Simon's finding that narcissistic damage resembled PTSD in many ways? Perhaps the problem isn't the character, but the cognition of the sufferer.

Kohut and Kernberg both believed that NPD was a product of developmental problems (Stevens et al, 1984). In Kohut's self-psychology theory, the NPD is created through a deficit of parental mirroring or parental rejection at the infancy stage. Unable to develop a bond with their primary caregiver, the NPD holds on to the idealization of their own ability to affect their environment, until they can develop a bond with the therapist, which allows them to learn the developmental skills denied them as children. In Kernberg's theory of pathological narcissism, the same lack of parental warmth causes the creation of a grandiose self, which is unable to care for anyone else. For years, these two theories were referenced almost exclusively in NPD studies.

A proposed integrated narcissism model set forth by Dimaggio et al (2002) has through research and study, outlined a complex set of cognitive processes and the means by which the disorder perpetuates itself. While Kohut and Kernberg's work are still at the model's foundation, the model focuses more on the immediate meta-cognitive defect of the NPD instead of the developmental processes that created it. Since therapists rarely deal with the NPD at the time of their developmental disruption, this model is probably far more useful in treating those in practice.

Traits versus contextual

Hummelen and Rokx (2007) discussed that one problem with personality disorders is that people display consistent personality traits on an inconsistent basis, depending on the context these traits occur in based on many variables. Therefore, it is possible that an individual could display non-pathological traits in the therapist's office, while displaying very pathological behaviors with neighbors who are not available for interviews. Likewise, an individual may display previously unknown pathological traits in an office due to abnormal fears and stress of meeting with a "shrink", much like a person whose blood pressure rises whenever he is examined by a physician.

Relying on the DSM

Hummelen and Rokx also criticized the syndromal approach of the DSM, with its highly ambiguous definitions based on often unobservable behaviors. Such definitions lead to generalizations and the expectation that certain behavior will always be present. There is almost no consideration of the context of the behavior. After all, a world class soccer player would legitimately be able to say he is the best in his field and be used to entitled treatment from others, but unless the person treating him followed the sport, they might doubt the patient's claims.

The DSM (APA, 2000) itself admits that the Cluster B personality disorders resemble each other. NPD can also resemble the obsessive-compulsive personality disorder, the schizotypal personality disorder, the paranoid personality disorder, and manic or hypomanic episodes. Using the DSM alone for identifying this disorder is an exercise in eliminating other possibilities.

Using the MMPI and MCMI

Chatham, Tibbals, & Harrington (1993) state in their study that NPDs only show a significant difference on the hypomanic scale using the MMPI. This means that MMPI could not differentiate between a NPD and a legitimately talented person experiencing a mild case of mania. The MCMI was even less clear, scoring the NPD high not only on the hypomanic scale, but also the histrionic, narcissistic, and antisocial scales too. Chatham et al concluded that more data was needed for diagnosing NPD than was provided by these tests.

Using the Rorschach Inkblot test

Surprisingly, one of the tests that has consistently been able to designate NPDs from other disorders has been the Rorschach Inkblot test. Harshly criticized in the 1990s, Ganellen (2001) and others have successfully defended the test, stating that it is just as accurate as the MMPI in overall use, as long as it was used for the purposes it was originally intended for - a diagnostic test based on perception alone, with little attention paid to the projections. Weiner (1996) gives four examples of successful applications for the Rorschach: differentiating personality variables; measuring developmental changes in children and adolescents; monitoring improvement during psychotherapy; and identifying experienced distress in war veterans with PTSD. There is also evidence in at least 48 studies that the Rorschach can detect cognitive complexity, reality testing, general psychological stress, disordered or psychotic thinking, and disturbances in object relations. Published longitudinal studies have shown that the Rorschach variables were steady over time.

The disturbances in object relations is of particular interest in regards to the NPD. Both Kohut and Kernberg were object relations theorists and their theories of pathological narcissism depended in disruptions in the development of self and object relations. In Kohut theory, NPDs had arrested development. In Kernberg's theory, they were created through a developmental aberration. (Stevens, Pfost & Skelley, 1984) Therefore, it stands to reason that the Rorschach test would be a better instrument to detect pathological narcissism. In studies done by Hilsenroth, Fowler, Padawer and Handler (1997), the four variables usually elevated in NPDs are reflection responses, personalized responses, idealized responses and the egocentric index. Of these four, two - reflection and idealized responses, were found to be empirically comparable to the DSM-IV diagnostic criteria.

In an earlier study by Hilsenroth, Hibbard, Nash & Handler (1993), borderline and narcissistic personality disorders showed several differences using the Rorschach. Ironically, borderline personality disorders (BPDs) tend to show higher grandiosity than NPDs, while NPDs were more egocentric. BPDs were also more aggressive and used more primitive emotional defense mechanisms than other PDs. This might explain the findings of Hummelen & Rokx (2007), where neuro-imaging scans show BPD patients to consistently have a smaller and hyper-reactive amygdala.

While the Rorschach can be defended as a diagnostic tool, it is still open to misuse in clinical settings. As Weiner (1996) pointed out, it was never meant to be used for everything, nor was it meant to be used by those not thoroughly trained in evaluating it. One hopes that now the ability to diagnose NPDs through object relations has been proven that a less subjective test can be devised for it.

CHAPTER 4. CONCLUSION

Based on studies using the Rorschach test, other psychometric instruments and documented case studies, the current prevailing professional view of the narcissistic personality disorder would be that it a deficit of meta-cognition, probably caused by a disruption of self-development in infancy. While it is not treated with medication, approaching NPD as a disorder is very important because it easier to be less emotionally hurt by the sufferer's actions. This emotional distance is necessary when dealing with NPDs, since it allows one some control over how they are seen by the NPD. To get anywhere with an NPD requires the individual to be seen as admirable.

Cognitive therapy is the only course so far that has shown any success in treating NPDs. Confronting a NPD and calling them to repentance is pointless in most cases. The narcissistic defence system is far too sophisticated to be dismantled by such tactics. At best, the NPD will retreat into a depressive state and cycle through emptiness and fear until they latch onto their grandiose self and return to their pathology when the immediate threat of shame is past. A more successful approach is to guide the NPD to a point of real achievement, in either the present or the past, and help them to realize that not being powerful all the time is nothing to be ashamed of.

It is very easy to see how a lay person would question the diagnosis of NPD as a mental disorder, based on the literature and websites available to them. Upon seeing the criteria for NPD, many would understandably declare its sufferers as difficult people who should just straighten up their acts. However, as we look closer at the studies of NPD, it becomes apparent that the narcissist is suffering from a cognitive defect, which uses a rigid value system as a coping mechanism. Because of this coping mechanism, NPDs will have character flaws, but the treatment of the disorder is not in the flaws, but in the cognitive deficits. In his confusing way, Sam Vaknin is correct about his disorder. It is something that the NPD suffer cannot completely control, however, through humility and responsibility they can overcome their cognitive deficits. In a way, it is not much different than a bipolar patient who must manage their symptoms. The jury is still out as to whether NPD can be completely cured. It is tricky enough just to get the patient into the therapist office in the first place.

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