Ms S came in for her second session late by 30 minutes. For the first session, her excuse for being late was that she was stuck in a meeting. This time she glanced pointedly at the clock saying, “Traffic can be terrible these days, now you need to give me 30 minutes extra for the time we’ve lost”. When I reminded her that my clinic policy states starting and ending sessions on time, Ms S got rattled “Can’t you make an exception? I don’t believe this. Alright then, I will pay you only for half the session”
People like Ms S can be frustrating and annoying to be around: a lot of us would categorise them as “difficult people”. This challenging group usually falls into a cluster of mental disorders called personality disorders. Ms S had a type of personality disorder called Narcissistic Personality Disorder.
Is narcissistic personality disorder the same as narcissism?
The narcissistic personality was first described in 1925 by Robert Waelder, a noted Austrian psychoanalyst, and the term Narcissistic Personality Disorder [NPD] came into use in 1968. The term Narcissism originates from Greek Mythology: a hunter named Narcissus known for his beauty, fell in love with his own reflection and was so mesmerised by it that he became rooted to the spot. Soon, unable to bear this unrequited love, Narcissus lost his will to live and committed suicide.
Narcissism essentially refers to a set of traits where there is pursuit of gratification or egotistic admiration of one’s idealised self-image and attributes. It was also at one time called megalomania—people who are arrogant, self-centred and manipulative. However, people with Narcissistic Personality Disorder are not in the truest sense narcissists. While their external behaviour may resemble the qualities of narcissism [grandiosity, exploitation, arrogance] internally they are people with self-esteem issues, with a tendency to be shame-sensitive, vulnerable, inhibited and anxiety-prone [Gabbard, 1989]. The external superior behaviour is frequently just an armor [or even a fragile shell] that covers an extremely vulnerable self.
The Diagnostic and Statistical manual [DSM-5] indicates that persons with narcissistic personality disorders usually display some or all the following symptoms, typically without the commensurate qualities or accomplishments
- Grandiosity with expectations of superior treatment from other people
- Fixated on fantasies of power, success, intelligence, attractiveness, etc.
- Self-perception of being unique, superior, and associated with high-status people and institutions
- Needing continual admiration from others
- Sense of entitlement to special treatment and to obedience from others
- Exploitative of others to achieve personal gain
- Unwilling to empathise with the feelings, wishes, and needs of other people
- Intensely envious of others, and the belief that others are equally envious of them
- Pompous and arrogant demeanour.
How does NPD develop?
People with narcissism may have a naturally strong bent toward competitiveness. The meaning children make out of their childhood experiences—especially overtly traumatic events or very negative and chronic experiences—may increase the expression of these inherited tendencies. Research finds that narcissistic personality disorder has higher prevalence among men and roughly occurs in 6% of the general population. NPD symptoms usually decrease with age, around the 40s, like most personality disorders.
There are two subtypes of NPD [Gabbard, 1989; Caligor et al 2015] recognised in the clinical setting. The grandiose [overt] tend more toward displays of self-importance, grandiosity, attention seeking, entitlement, arrogance, fantasies of admiration, denial of weakness, and exploitative behaviour. The vulnerable [covert] are more likely to be shy, self-effacing, “fragile” or thin-skinned. They are hypersensitive to the evaluations of others while chronically envious and evaluating themselves in relation to others. It is theorized that the subtypes develop because of the different approaches of earlier caregivers: overly indulgent with extravagant praise versus cold with excessive expectations. Both types are extraordinarily self-absorbed.
The narcissistic beliefs about the Self
It is important to note that the traits of narcissism can also characterise highly successful individuals with high self-esteem [American psychiatric association, 2000]. However, people with high self-esteem are confident of their personal worth because their esteem is based on realistic self-appraisals of demonstrated talents and achievements. Corrective feedback does not trigger a dramatic loss of self-esteem. For the person with NPD, self-esteem is established by outward success and they remain firmly rooted in the importance of a flawless or powerful image, like Narcissus remained rooted to the spot while admiring his reflection. Without a flawless image, core beliefs of inferiority become activated.
People with NPD thus swing between two extreme internal views of self. When others are disregarding or critical, their internal dialogue is “I am inferior, nothing, a piece of garbage”. On the other hand, when receiving accolades or special treatment they swing the other way believing “I am superior”. In a similar fashion, they view the world also with disdain [people are more inferior than me] and swing the other way when others gain success [people are superior, hurtful, demeaning].
Soon there is erosion of their functional world—their success becomes dotted with evidence of difficulties in the workplace, inappropriate anger, exploitation of others [e.g., deceit, sexual harassment], legal difficulties, and financial problems resulting from grandiosity and entitlement.
Dealing with a person who has NPD
Recovery for people with NPD is usually difficult as they bring to therapy the same strategies that they use to cope with the outside world- trying to impress the therapist, punishing the therapist when feeling slighted [through criticism, snide remarks], demanding entitlements and treating the therapist as an inferior. Creating an alliance with the NPD patient requires special skill because the main internal relationship pattern [dyad] embedded in the patient’s mind is that of a superior person in relation to an inferior one.
As a therapist, I learnt the following mantras when communicating with people diagnosed with NPD. Some of these may be useful to you when dealing with a loved one who has NPD:
Develop a thick skin
I typically ignore slights and put-downs and use either respect or humour to manage the attack. A client with NPD, came in early to his first session and examined every certificate in my waiting room. He then picked one of my award trophies, carried it to the therapy room and sneered “Are you sure you didn’t buy this for 1000 bucks at a store? Just kidding doc”. My response [grinning] “Let’s make sure the organisers of that award don’t hear that”
Lay limits without judgment
I adopt a strategy of firmness with politeness when setting limits with NPD clients [which is usually quite often]. Eg: Speaking loudly on their phone in the waiting area is managed with a “Hope the sign was visible outside stating silence in the waiting area as it disturbs the client in the therapy room”
Defer to them
I often have a client with NPD showing off their designer watch or giving me advice on furnishing my office more tastefully. I usually reply “Oh that’s a nice watch” or “Yes, you are right, the colour scheme of this room can be changed”. Using the assertiveness principal called fogging which means “agree in part, or in principal”, is helpful to deal with such messages.
Be a good person
Look below the surface to the pain and low self-esteem that lies below. A patient was affronted because I didn’t accept her friend request on social media. “It’s nonsense that you don’t want your patients on social media because of ‘boundaries’. In reality you are afraid people will see that you hardly do any real work, unlike your other colleagues. You are trying to hide the fact that you are a second-rate psychologist”. While this attack was harsh, I framed the discussion such that the reasons for her statements emerged. One of the questions I asked her “What did it mean to you when I refused your friend request?” Slowly, her rejection sensitivity came to the surface.
Recovery is possible
People with NPD have been conditioned since childhood to over-use certain coping strategies. They believe that demanding special treatment from others, being hypervigilant to insults, punishing others when feeling hurt, trying to impress people and trying to compete, is “normal” expected behaviour. Many people with NPD do not know that their behaviour and feelings are abnormal because they have nothing to compare it to. It could be very late in their life when they first start to realise that a lot of people don’t feel the way they do.
In their journey towards recovery, people with NPD need to develop ways to blend in with the general population, discover their own unique potential and feel truly confident about themselves. Some of the replacement strategies they need to develop are:
- Cooperating with others toward achieving a common goal.
- Being comfortable with others’ achievements
- Tolerating inconveniences, frustration, lack of recognition.
- Developing an attitude of optimism
- Meeting others’ expectations without great benefit to self.
When I see a client with NPD slowly changing their ways of thinking and developing true inner confidence, this quote by Mother Teresa comes to mind “If you are humble nothing will touch you, neither praise nor disgrace, because you know what you are.”
Examples cited are modified in order to protect the client’s identity.
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