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In a normal relationship, it goes something like this: Two people catch that distinct twinkle in each other’s eyes. Typical behaviors unfold, like flirting, followed by a test of the suitor’s capacity for witty banter. Soon, good morning texts with kissy face emojis start to regularly ping. The pair experiences joy and laughter over espresso and indulgent bites of tiramisu. Weeks stretch into months, and deep emotional connections ignite the honeymoon phase of the relationship. Bliss.
Now, for the not-so-normal relationship: where one person is a narcissist. Kissy face emojis go rogue while good morning texts arrive in scarce supply. Anxiety and confusion set in for the other person. Shared desserts start to taste bland while the narcissist grows obsessed with their phone. Witty conversations are replaced by sentences such as, “I don’t know.” Loneliness and isolation ice over the honeymoon stage, thanks to petty arguments, silent treatments, and explosive bouts of rage.
As you watch someone’s personality slowly unhinge and the relationship fall apart due to narcissistic behaviors, the obvious questions become: Can this person be fixed? What drives narcissists to be narcissists? And finally, is narcissism a mental disorder?
Let’s start with the last question first. Since 1980, a form of narcissism has been recognized in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM) as narcissistic personality disorder (NPD), where it is defined as a personality disorder comprising “a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.”
Web MD describes personality disorders as mental disorders caused by an unhealthy pattern of thought and behavior, and divides them into categories known as clusters. “People with personality disorders often struggle to interact with the world. Their disorder makes it hard for them to understand social situations and relationships,” says the website, which lists NPD in the Cluster B category, alongside antisocial, borderline, and histrionic personality disorders.
Drawing the distinction between taking a healthy ego to extremes and an NPD diagnosis is an interesting question. In 2009, Emily Yoffe, a contributing editor at The Atlantic, summed it up this way for Slate: “The problem occurs when narcissism becomes the primary principle of someone’s personality. Its most extreme form is NPD, a psychological condition that impairs a person’s ability to form normal relationships and wreaks havoc on those who have close encounters with it.”
The Treatment Factor
The question of fixing someone through treatment is a bit more complicated, however. That’s mainly because NPD is a less studied condition than most other disorders. One reason for a lack of treatment, say experts, is that narcissists rarely show up in a therapist’s office. Another is that there are no pharmaceutical fixes. A survey study in the American Journal of Psychiatry, in which only ten percent of invited psychiatrists and clinical psychologists responded, found that “clinicians reported feeling anger, resentment, and dread in working with narcissistic personality disorder patients; feeling devalued and criticized by the patient; and finding themselves distracted, avoidant, and wishing to terminate the treatment.”
NPD can run on a continuum from mild to severe, and to develop effective treatment protocols, it’s important to understand its origin and pathogenesis. But because of difficulties encountered in studying this disorder, researchers and clinicians must piece together scientific findings from the few systematic reviews and meta-analyses that exist for NPD.
“We know that NPD is heritable and genetic even when compared to other personality disorders,” says Royce Lee, M.D., psychiatrist and associate professor of psychiatry and behavioral neuroscience at the University of Chicago. “There’s a twin study that seems to suggest among the different personality disorders, its heritability is the highest.”
Adding the nature versus nurture question generates theories suggesting that NPD and other personality disorders originate from childhood trauma that affects emotional development in the brain. The hypothesis holds some plausibility, says Lee, who specializes in trauma and whose research team has found a link to oxidative stress (an imbalance between free radicals and antioxidants in the body) and personality disorders.
There are three subtypes of NPD: classic, exhibitionist, and high-functioning; the latter has the highest severity of poor psychosocial and interpersonal functioning. Lee says it is also important to consider how personality disorders manifest within different cultures; narcissistic personality disorder will not look the same in western society compared to eastern society, for example. He adds that taking cultural considerations into account could also help clinicians better diagnose and treat people with such personality disorders that may be tied to obsessive compulsive behavior and paranoia.
Lee says that cultures express things differently and speculates and that “if you view NPD as a stress-related disorder, racism or other factors can increase the rates of the disorder.” For example, the drive to accumulate wealth is a mindset often tied to narcissism with deep roots in western culture, Lee believes. In contrast, in non-western cultures that put more emphasis on the approval of others and a “de-centered self,” narcissism may likely play out much differently. That’s why it’s crucial to take cultural consideration and diversity into account during personality disorder assessments.
When Narcissists Go Too Far
On the surface, people with narcissistic traits typically display common, yet harmless, behavioral patterns, including overconfidence, a sense of entitlement, arrogance, or the need for constant praise and admiration. The DSM cites such traits as those of the “grandiose narcissist.” In comparison, the traits of the vulnerable narcissist run to cognitive challenges like low self-esteem and depression.
Some narcissists share somewhat darker traits—deception, devaluation, gaslighting, manipulation, and control—linked to emotionally and psychologically abusive behavior. Some of these behavioral patterns are documented in the Springer Nature journal Borderline Personality Disorder and Emotion Dysregulation, where a questionnaire study included verbatim reports from family members and current or former romantic partners of narcissists.
One researcher, Brin Grenyer, senior professor at the University of Wollongong Australia and director at Project Air Strategy for Personality Disorders, has found that narcissism is commonly underreported. The study delineates grandiose versus vulnerable narcissistic traits and finds significant overlap between them—with 69 percent of respondents reporting both characteristics. Because narcissists may oscillate between grandiose and vulnerable—the term “pathological narcissism” more broadly describes the disorder.
Lee points out that the true number of people diagnosed with NPD is difficult to calculate—but that it is likely higher than the 0.5 to 5 percent currently reported in the US. “There’s an overdiagnosis of bipolar, when in fact a personality disorder is the better or more accurate diagnosis—and is more predictive of what treatments will be helpful,” Lee says, adding that both NPD and bipolar disorder can coexist, but require different treatment protocols.
Only when a clinician feels that a patient is suffering from bipolar disorder in addition to NPD will medication be prescribed. Otherwise, NPD is generally treated through psychotherapy alone. Lee says more research is needed to make medication a treatment option for NPD. Grenyer agrees, adding, “One of the new frontiers in research is to develop better ways to understand and treat both those with narcissistic traits but also those close to them who themselves can be suffering.”
Processing Deception in the Brain
Some have suggested that narcissists have a greater-than-average propensity to lie, perhaps to self-enhance desirable traits. We know that every human lies—from giving false compliments, to making excuses, to taking sick days. Turns out, some people lie more than others. And thanks to neuroimaging, neuroscientists can differentiate between truth-telling and lying and get to those untruths associated with personality disorder.
One study that examined lying in people with NPD suggested associations between deceptive behavior and both narcissistic traits and self-assessed lying ability. Narcissists are prone to deception, and some actually consider themselves more skilled at lying than the average person. Based on investigations, the researchers discovered positive associations between lying and deceptive communication with narcissism.
In another study about lying, researchers found changes in brain activity that correlate with snowballing lies—known as “dishonesty escalation.” To explore the phenomenon, researchers used brain imaging while subjects carried out behavioral tasks that allowed them to lie repeatedly. Neil Garrett, Ph.D., lead study author and a cognitive neuroscientist at the University of Oxford, says the behavioral findings indicate that over time, dishonesty increased, and imaging showed that signal reduction in the amygdala is sensitive to dishonest behavior.
Lena Sisco, a former Navy intelligence officer and Marine Corps-certified interrogator who now consults with federal and state law enforcement agencies on criminal cases, says that when the average person lies, a natural stress response causes cognitive abilities to diminish as the limbic brain kicks into high gear. “The limbic brain overrides the thinking brain, and we become more irrational and emotional,” she says. “And because of diminished cognitive ability, we can’t even comprehend simple questions and tasks.”
Powerful liars, not specific to NPD, are described by Sisco as people who appear more skilled in deception, not because they are, but because they get away with it and have different motivations. “They do not get nervous when they lie and therefore appear calm, cool, and collected,” she says, citing findings from Aldert Vrij, a professor of psychology at the University of Portsmouth in England. Vrij examined examined deception through fMRI imaging and found that different neural activity takes place with deceptive individuals. Sisco adds that powerful liars primarily care about reward and will do whatever it takes at any cost—even when it may hurt others.
Cortisol, a hormone linked to stress, is suppressed so it isn’t going into the limbic system of the brain, says Sisco. “Their stress response system has not been triggered; that is why we do not see them looking nervous or showing physiological indicators a polygraph can detect.” She adds that when it comes to detecting lies, fMRI is more reliable than polygraph tests. However, ethical questions surround the use of such an invasive test for all personality disorders.
Neuroimaging Detects Emotions
Another hallmark sign of NPD is emotional dysregulation. A type of fMRI called voxel-based morphometry suggests structural abnormalities in the narcissist’s frontal-paralimbic brain region. Specifically, lower-volume gray matter in images of people with NPD is associated with restricted ability for emotional empathy, according to study authors.
fMRI findings suggest that the anterior insula region orchestrates aspects of empathy and compassion—traits that narcissists often lack. This region is also thought to influence interpersonal decision-making—such as an individual’s ability to express traits like fairness and cooperation. Feelings of entitlement and superiority allow narcissists to justify rule-breaking and playing by their own set of rules—even when it’s unlawful.
Seeking Treatment for NPD
Research and data are lacking on the rationale for outcomes for various forms of treatment currently used, and advances will depend upon advancing treatment studies.
In the opinion and experience of Sharie Stines, Psy.D., a therapist and author of Narcissist Survival Guide, narcissists lack the “blueprint” that allows “healthy interpersonal bonding,” perhaps the result of childhood trauma and negative parental involvement that disrupt natural processes.
Stines uses a variety of therapeutic methods designed to help patients change their current thought process. “In order to heal, they have to create a new blueprint or template out of scratch. I do this using psycho-education, cognitive restructuring, and imagery,” she says. Psychoeducation is a holistic therapy that draws on cognitive-behavioral therapy, learning theory, and group practice to encourage collaboration, coping, and empowerment. Similar approaches are used to treat schizophrenia.
Stines is among therapists who also use Eye Movement Desensitization and Reprocessing (EMDR)—originally designed to alleviate the distress associated with traumatic memories—to help people with NPD resolve unpleasant responses to unpleasant memories. It has also shown positive outcomes in creating a more realistic self-identity, which can help the narcissist resolve their feelings of superiority.
In their 2009 book, The Narcissism Epidemic, psychologists Jean M. Twenge and W. Keith Campbell write: “Despite the popularity of narcissism as a label, it is difficult to find scientifically verified information on it outside academic journal articles. Many websites on narcissism are based on some combination of conjecture, personal experience, and poorly understood psychoanalytic theories.”
If NPD is truly on the rise, as the data suggests and social scientists believe, society will suffer as work ethic and intellectual interest decline. More aggression, relationship complications, and a lack of empathy are also unavoidable. Write the authors: “Understanding the narcissism epidemic is important because its long-term consequences are destructive to society.” Advancing the research and treatment on NPD and all personality disorders is long overdue.
This article first appeared in the Summer 2021 issue of our Cerebrum magazine. Click the cover for the full e-magazine.