Narcissistic Personality Disorder (NPD) has gotten a lot of bad press. If you or a loved one have been diagnosed with this disorder, you may have many questions about what it means, what to expect, and maybe even how to feel.
If you’ve done any reading about narcissism, you’ve probably come across words like “vain,” “entitled,” “arrogant,” or “grandiose.” While words like these dominate pop-culture articles on narcissism, most people only have half of the picture.
There is an interesting history surrounding this term that has led many (including some clinicians) to misunderstand what narcissism really is.
In the 1980s, the American Psychiatric Association (APA) revised its diagnostic manual (DSM-III-R) in an attempt to make it less theoretically biased. Following this revision, the new diagnostic criteria for NPD were streamlined to focus entirely on the overt, grandiose features with which the term has become synonymous. People came to believe that NPD was all about vanity and entitlement, which led to a stigmatization of the disorder. Today, the word narcissist is often used as an insult.
However, the kind of narcissism presented in the media is only half the picture. In fact, many people with NPD struggle with low self-esteem, feelings of shame, alienation, chronic depression, and anxiety.
The vulnerable side of narcissism
There is a substantial body of literature (for a review, see Ettensohn, 2010) suggesting that there are actually two faces of NPD. The one we are all familiar with is called overt or grandiose narcissism. The less recognized one is called covert or vulnerable narcissism.
An easy way to think about this is to imagine the old horseshoe shaped magnets with which we are all familiar. The north and south poles have different properties that are based on the underlying principles of magnetism. It would be inaccurate to say that the two poles are different magnets entirely. They are different parts of the same magnet. Similarly, Grandiose and Vulnerable Narcissism are different poles of an underlying principle called core narcissistic conflict.
Okay, so what is core narcissistic conflict?
Core narcissistic conflict is actually a complicated idea. To really simplify things, people who struggle with core narcissistic conflict have trouble connecting with their authentic self. The authentic self is that place inside each of us that is the wellspring of vitality, sincerity, sorrow, and joy. People who are disconnected from this authentic self may report that they don’t know who they really are, or what they really want. They may have difficulty describing what makes them happy, what they really value, or how they really feel. Often, they have very little sense of their intrinsic value as a person.
Core narcissistic conflict causes a person to feel like they aren’t deserving of love unless they are good enough. They try to become good enough by hiding their real feelings (even from themselves) and substituting a false self in place of their authentic self.
The false self
A false self is a clinical term for a mask that someone wears – a persona that they adopt because it’s what they think other people want them to be. They may even be so used to it that they have come to believe it is who they really are.
The false self is all about being good enough. Unlike authentic self experience (which is intrinsically validating), the false self requires outside validation. People who have adopted a false self depend on being perceived as beautiful, talented, successful, funny, smart, or accomplished. The problem is that none of these attributes have anything to do with a real person. They describe what a person can do, not who a person is on the inside.
The tragedy of core narcissistic conflict is that the person feels he or she is only lovable when they are wearing the mask of the false self. The underlying authentic self goes unnoticed, and the person’s needs for care and acceptance get neglected. At the center of the person there is a never-ending need for love that never gets met. As you can imagine, this is a recipe for emotional suffering.
When the false self breaks down
The false self is a defensive facade. The person uses it because he or she believes it’s who they are supposed to be. They believe the false self protects them from rejection and abandonment. But the price for feeling protected is that the person gets stuck in a never-ending cycle of approval-seeking.
Like any defense, sometimes the false self gets weakened, leaving the person exposed to the underlying fears about not being good enough. The person may feel ashamed, depressed, worthless, anxious, panicked, or experience intense worries about death or sickness (hypochondria). This is vulnerable narcissism – the other pole of the magnet. Many people with NPD seek therapy in this state of emotional distress, and many clinicians who are not trained to recognize core narcissistic conflict will simply diagnose the person with dysthymia, major depression, or generalized anxiety disorder.
Different configurations of NPD
People with NPD can fluctuate between the grandiose and vulnerable poles of the magnet. To use a different metaphor, it’s sort of like a radio dial with “very vulnerable” at one end and “very defended” at the other end. A person can be anywhere in between. While some people spend most of their time in the defended position, others spend most of their time in the vulnerable position.
When a person’s false self defenses are working well, he or she is often unconscious of the underlying vulnerability. That doesn’t mean it is gone…it’s just hidden by the defenses. Entitlement hides a feeling of deep impoverishment, confidence hides a feeling of worthlessness, vanity hides a feeling of being undesirable, and charm hides a feeling of despair. Just as the sense of superiority is fueled by the need to avoid feeling worthless, the feeling of worthlessness is fueled by the sense that one should be superior. Unrealistic standards underlie both the grandiose and vulnerable aspects of NPD.
How is NPD treated?
The only effective treatment for NPD is therapy. Because it is a personality disorder (meaning it has to do with the basic ways a person relates to self and others), treatment takes time. It may take a year or more to notice lasting improvement.
What will treatment be like?
NPD is treated by addressing the underlying core narcissistic conflict. The person must be helped to recognize the false self as something that actually keeps them stuck in a never-ending pursuit of self-worth. They must also be helped to work through the vulnerability that emerges when their defenses break down. It can be a difficult process. But with time and a therapist trained to help the person connect with their authentic feelings, the false self defenses gradually diminish. As the person becomes more connected to their intrinsic worth as a person, they rely less on those around them for self-esteem maintenance.
Don’t be discouraged!
With treatment, many people with NPD are able to develop a more stable sense of self-esteem. The most important thing is to stick with treatment! Recovery takes time. It is often a difficult and frustrating process, but well worth it when you consider the possibility of having more satisfactory and meaningful relationships with yourself and those you care about.
If you have further questions about NPD, talking with a therapist can help. If you would like to contact me with questions about treatment for NPD, I can be reached by telephone or through this contact form.
Ettensohn, M.D. (2010). The relational roots of narcissism: Exploring relationships between attachment style, acceptance by parents and peers, and measures of grandiose and vulnerable narcissism. (Doctoral dissertation). Retrieved from Dissertations & Theses: Full Text. (Publication No. AAT 3515488).
*For a more technical account of diagnostic issues surrounding NPD, see this article, published by Dr. Ettensohn in the monthly newsletter of the Sacramento Valley Psychological Association: Toward a Functional Understanding of Psychopathology: The DSM-IV-TR and Narcissistic Personality Disorder
Before the patient knows what will make him feel good, he must feel. When the narcissist truly begins to feel, among his first feelings will be that injury, that hurt, that humiliation, which drives the grandiose false self in its quest to prove self-worth.”
– Stephen Johnson