INTERNAL PROCESSING IN PATIENTS WITH PATHOLOGICAL NARCISSISM OR NARCISSISTIC PERSONALITY DISORDER: IMPLICATIONS FOR ALLIANCE BUILDING AND ...
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Journal of Personality Disorders, 34, Special Issue, 80–103, 2020
© 2020 The Guilford Press
INTERNAL PROCESSING IN PATIENTS
WITH PATHOLOGICAL NARCISSISM OR
NARCISSISTIC PERSONALITY DISORDER:
IMPLICATIONS FOR ALLIANCE BUILDING
AND THERAPEUTIC STRATEGIES
Elsa Ronningstam, PhD
Pathological narcissism (PN) and narcissistic personality disorder (NPD)
have primarily been identified by striking external features, such as
superiority, attention seeking and a critical or condescending attitude,
and less attention has been paid to the internal processing contributing
to this particular personality functioning. High dropout from treatment
and challenges in building a therapeutic alliance with these patients call
for further understanding of the complexity of disordered narcissism.
Recent research on neuropsychological underpinnings to narcissistic
pathology have provided valuable information that can inform
therapeutic interventions for patients with this personality pathology.
Internal processing in patients with PN or NPD is specifically influenced
by compromised emotion processing and tolerance, identity diffusion,
fluctuating sense of agency, reflective ability, perfectionism-related self-
esteem, and ability to symbolize. The aim of this article is to review
research studies with relevance for internal processing related to disordered
narcissism and integrate findings with therapeutic strategies in alliance
building with these patients.
Keywords: emotion regulation, perfectionism, narcissistic personality
disorder, sense of agency, self-esteem, self-reflective ability
Patients with pathological narcissism (PN) or narcissistic personality disorder
(NPD) present with a wide range of functioning and clinical characteristics.
In addition to the standard diagnostic features, subtypes of NPD range from
overt and grandiose to covert and vulnerable, and level of function can be
exceptionally high with outstanding competence as well as extremely low,
accompanied by different comorbid conditions (Caligor, Levy, & Yeomans,
2015; Gabbard & Crisp, 2016; Pincus & Lukowitsky, 2010; Yakeley, 2018).
Pathological narcissism and NPD as defined in the Diagnostic and Statis-
tical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric
From Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
Address correspondence to Elsa Ronningstam, McLean Hospital AOPC Mailstop 109, 115 Mill St., Belmont
MA 02478. E-mail: ronningstam@email.com
06_G4784_449.indd 80 3/11/2020 2:03:02 PMINTERNAL PROCESSING IN PATIENTS WITH NPD 81
Association [APA], 2013), sections II and III, and the second edition of the
Psychodynamic Diagnostic Manual (PDM-2; Lingiardi & McWilliams, 2017)
(see Table 1) are challenging conditions that often can interfere with alliance
building and prevent changes in treatment. Patients with NPD tend to drop
out early (Ellison, Levy, Cain, Answell, & Pincus, 2013; Hilsenroth, Holdwick,
Castlebury, & Blais, 1998), and disagreements, disruptions, and stalemates
in treatment are common (Gabbard & Crisp, 2018; Ronningstam, 2014).
Therapists’ early interventions—for example, pointing to an observed discrep-
ancy between the patient’s verbal and emotional presentations—can be well
intended and solidly anchored in psychoanalytic or psychodynamic theory, or
in evidence-based treatment strategies for personality disorders. Nevertheless,
they can often evoke patients’ defensive reactions or lead to power struggles.
Similarly, interventions influenced by therapists’ direct observations of patients’
immediate interactive or behavioral functioning tend to escalate the patients’
oppositional or defensive reactions.
Traits and dimensions that diagnostically define PN and NPD, that is,
the official diagnostic criteria (DSM-5, sections II and III; PDM-2) (Table 1)
can provide an estimation of narcissistic personality functioning, but they
do not fully inform about the underlying subjective internal processing that
constitutes the core of narcissistic pathology. The common characteristics of
PN—arrogance, critical, condescending attitude, and superiority, which at
times can be very striking and provocative—tend to redirect the therapists’
attention away from patients’ subjective experiences and reasoning. In addi-
tion, narcissistic aggressivity (O. F. Kernberg, 1992) can remain internalized
as well as externally and interpersonally expressed in different ways. This
discrepancy between patients’ external presentation and internal processing
can easily cause incorrect assessments, misdiagnoses, and ineffective interven-
tions, especially in the early phase of alliance building. The therapist’s efforts
to find the optimal strategy to treat a patient’s specific narcissistic character
disorder can be derailed by the interpersonal challenges in the emerging alli-
ance between therapist and the individual patient.
Correlates and underpinnings of the common expressions of pathological
narcissism can be well hidden and difficult to access. Patients’ nondisclosure
and compromised ability to identify and verbally convey emotions and subjec-
tive internal experiences, combined with their narcissistic defensive stand and
interpersonal patterns or reactivity, require specific attention and strategies in
the initial assessment and alliance building (Ronningstam, 2012). This also
calls for a better integration of therapeutic interventions with understanding
of the individual patient’s specific narcissistic functioning and related life
circumstances.
Complex interactions between mind, brain, and attachment patterns
unfold in interpersonal interactions, both in patients’ real life and in treatment,
in the relationship to the therapist. In addition, the etiology, comorbidity, and
specific life circumstances together form unique and complex patterns in each
patient’s narcissistic pathology and functioning. Further awareness of these
internal patterns and processes can improve the understanding of patients
with PN and NPD, and guide the therapists’ strategies and interventions in
the alliance building.
06_G4784_449.indd 81 3/11/2020 2:03:02 PM82 RONNINGSTAM
TABLE 1. Diagnostic Features for Narcissistic Personality Disorder
Diagnostic traits Dimensions Key features
1. Grandiose sense of self-importance 1. Identity Central tension/preoccupation
2. Preoccupied with fantasies of Excessive reference to others for self- Inflation and deflation of self-
unlimited success, power, brilliance, definition and self-esteem regulation esteem
beauty or ideal love
3. Believes he/she is “special” and Exaggerated self-appraisal inflated or Central affects
unique and can only be understood deflated,or vacillating between extremes
by, or should associate with other
special or high-status people or
institutions
4. Requires excessive admiration Emotional regulation mirrors fluctuations Shame, humiliation, contempt,
in self-esteem. envy
5. Sense of entitlement, unreasonable 2. Self-direction Pathogenic beliefs about self
expectations of especially favorable
treatment or automatic compliance
with his or her expectations
6. Interpersonally exploitative, takes Goal setting based on gaining approval “I need to be perfect to feel ok.”
advantage of others to achieve his or from others
her own ends
7. Lacks empathy, is unwilling to Personal standards unreasonably high in Pathogenic beliefs about others
recognize or identify with feelings or order to see oneself as exceptional, or too
needs of others low based on sense of entitlement
8. Envious of others, or believes that Often unaware of own motivations “Others enjoy riches, beauty,
others are envious of him or her power, and fame: the more of
those I have, the better I will feel.”
9. Arrogant, haughty behavior or attitude 3. Empathy Central ways of defending
Impaired ability to recognize or identify Idealization, devaluation
with the feelings and needs of others
Excessively attuned to reactions of others,
but only if perceived as relevant to self
Over- or underestimate of own effect on
others
4. Intimacy
Relationships largely superficial and exist
to serve self-esteem regulation
Mutuality constrained by little genuine
interest in others’ experiences and
predominance of a need for personal gain
Traits
1. Grandiosity
Feelings of entitlement, either overt or
covert
Self-centeredness
Firmly holding to the belief that one is
better than others
Condescending toward others
2. Attention seeking
Excessive attempts to attract and be belief
the focus of others’ attention
Admiration seeking
Source: American Psychiatric Association. Source: American Psychiatric Association. Source: Lingiardi, V., & McWilliams,
(2013). Diagnostic and statistical manual (2013). Diagnostic and statistical manual N. (Eds.). (2017). Psychodynamic
of mental disorders (5th ed.). Washington, of mental disorders (5th ed.). Washington, diagnostic manual: PDM-2 (2nd
DC: Author. Section II. Reproduced with DC: Author. Section III. Reproduced with ed.). New York, NY: Guilford. p. 48.
permission. permission. Reproduced with permission.
06_G4784_449.indd 82 3/11/2020 2:03:02 PMINTERNAL PROCESSING IN PATIENTS WITH NPD 83
The first aim of this article is to define and outline different aspects of
the internal processing in patients with PN or NPD, as they are influenced
both by temporary pathological narcissistic reactivity and by deeply engrained
characterological and neuropsychological patterns. Of specific importance is
the connection between internal processing and identifiable diagnostic fea-
tures, so that the second aim of this article is to connect these two aspects of
pathological narcissism.
EXTERNAL CHARACTERISTICS VERSUS
INTERNAL EXPERIENCES
The discrepancy between the external presentation and the internal process-
ing in patients with PN or NPD has long been confusing, especially since the
content and intensity of their internal experiences can remain hidden. Obvious
narcissistic interpersonal patterns, often enacted in relationship to the thera-
pist, include self-enhancement, critical devaluation, dismissiveness, avoidance,
aggressivity, and various manipulative maneuvers to preserve control, distance,
and self-esteem. In different moments, the patient is also accessing his or her
own thoughts, images, and visceral as well as emotional reactions that are
activated within the alliance to the therapist. Those can be well hidden or inac-
cessible behind the facade of typical narcissistic features, especially escalated
self-enhancement (Ronningstam, 2017). Usually referred to as resistance or
negative transference, this has contributed to a blaming and unhelpful attitude
towards patients with PN or NPD. However, an alternative view suggested
by Eaton and colleagues (2017) and influenced by transdiagnostic research,
identified internalized distress and fear in NPD, and the authors concluded that
NPD could be conceptualized as a distress disorder. Another study by Kealy
and colleagues (Kealy, Ogrodniczuk, Joyce, Steinberg, & Piper, 2015) found
anxious attachment and vulnerable self-experience of inadequacy, fearfulness,
and sensitivity to rejection to be associated with narcissistic grandiosity. They
also identified lower quality of object relations, with intolerance of separation
and dependent or controlling relationship patterns. The authors conclude
that narcissistic grandiosity co-occurs with insecure self-representations and
sensitivity to rejection. This supports the need for further exploration and
identification of context and underpinnings of narcissistic pathology that
contribute to these patients’ specific internal struggle in contrast to their typi-
cal external presentation.
INTERNAL PROCESSING
Internal mental processing has primarily been attended to in cognitive psy-
chology as a mediational process between stimulus and response, including
imagination, memory, attention, and perception. For the purposes of this
article, internal processing is used as an umbrella concept referring to cognitive
and emotional as well as relational mental activities that can contribute to the
individual’s self-regulation, degree of reactivity, and ability for awareness and
06_G4784_449.indd 83 3/11/2020 2:03:02 PM84 RONNINGSTAM
assessment of self and others. Several factors can influence the nature of inter-
nal processing in NPD: fragmented and fluctuating sense of identity; automatic
or intentional efforts to avoid or hide specific aspects of self; compartmental-
ized attachment patterns, in particular avoidant and dismissive (Diamond &
Meehan, 2013); and internalized object relations, shifting between idealized
and devalued (O. F. Kernberg, 1976). In addition, overwhelming hypersensitiv-
ity and reactivity (visceral, psychosomatic, or affective) tend to supersede or
overpower actual awareness of and ability to verbalize internal experiences.
Internal processing is also affected by considerable underpinnings, such
as inheritance and temperament, including hypervigilance, aggressivity, frustra-
tion intolerance, and high novelty seeking (Cloninger, 2000; Torgersen et al.,
2012). Attachment patterns, in particular dismissive, avoidant, and anxious-
preoccupied patterns (Diamond et al., 2014), and gaze—that is, implications
of being seen and seeing associated with shame, humiliation, and retreat
(Steiner, 2006)—are also significant developmental components that affect
narcissistic functioning. Internalized unintegrated self-object relations play
a major role in experiences of and reactions to self and others in social and
interpersonal contexts (O. F. Kernberg, 1976). In addition, age-inappropriate
role assignments and childhood psychological trauma (P. F. Kernberg, 1998;
Maldonado, 2006; Simon, 2002) can have employed significant subjective
meaning but remained compartmentalized and unverbalized. Such experiences
can continue to have a major impact on the individuals’ perception of self
and others, with accompanying reactions in different situations. Exploration
of patients’ developmental history is particularly important especially in the
phase of alliance building.
Recent studies focusing on neuropsychological aspects of emotion and
interpersonal processing have identified several significant components and
functions related to NPD and PN. One study using MRI scans to assess gray
matter deficits in patients diagnosed with DSM-IV NPD suggests a neuro-
logical core for noticeable emotion dysregulation and fluctuations in internal
control and control of emotions in NPD (Nenadic et al., 2015). Another study
measured respiratory sinus arrhythmia and the cardiac pre-ejection period, and
identified a psychophysiological base for emotional reactions in NPD (Sylvers,
Brubaker, Alden, Brennan, & Lilienfeld, 2008). An additional study of facial
expressions confirmed deficits in recognition of emotions in NPD patients,
indicating possible underpinnings to narcissistically based interpersonal insen-
sitivity (Marissen, Deen, & Franken, 2012). Noticeable self-centeredness and
tendencies to disengage were verified in two fMRI studies that suggested an
internal predisposition for self-preoccupation in individuals with PN, and an
automatic shift from inter- to intra-subjective focus when facing own and
others’ emotions (Fan et al., 2011; Scalabrini et al., 2017). Marcoux and
colleagues (2014) found stronger somato-sensory resonance combined with
deficits in affective and empathic responses towards others’ pain in patients
with NPD using EEG measurement. The authors identified a cerebral reactivity
to painful stimuli with a sensory-cognitive approach to assess others’ pain.
This suggests an ability to feel but compromised incentive for caring responses.
Further studies have provided evidence for compromised empathic function
in NPD, that is, intact cognitive but neural-deficient emotional empathy, and
06_G4784_449.indd 84 3/11/2020 2:03:03 PMINTERNAL PROCESSING IN PATIENTS WITH NPD 85
impact of emotion intolerance and processing on ability to empathize (Ritter
et al., 2011).
Taken together, these studies provide evidence for a neuropsychological
core deficit in emotion processing in individuals with PN or NPD, which affects
their ability to access, tolerate, identify, and verbalize emotions. Studies vary
with regard to sensitivity and reactivity, but point towards a hyper-reactivity
but not necessarily an accompanying interpersonal responsiveness in NPD.
One study of facial emotion recognition confirmed that subjects with high
NPD traits showed increased sensitivity for subtle cues of non-acceptance
in negative or neutral facial expressions, which contributed to their intense
angry feelings and accompanying self-focus (De Panfilis et al., 2019). This can
further explain the often-contradictory presentations of narcissistic individuals
as either or both hyper-vigilant and reactive or insensitive and dismissive. In
other words, automatic autonomic reactions can be ingrained or compart-
mentalized, and readily triggered in specific interpersonal contexts. Similarly,
self-centeredness and a need for internal control with fear of losing control
also influence narcissistic interpersonal interactions.
Internal processing can be context dependent and obvious, and activate
severe pathological narcissism in patients even in the absence of a full diagnosis
of NPD. Internal processing can also fluctuate and be noticeable, but never-
theless remain out of reach for verbal exploration and diagnostic assessment.
Patients with PN or NPD are known for making intentional efforts to present
in certain ways to evoke explicit impressions on others. However, they can
also be totally unaware of the impact they have on others in general or on the
therapist in particular. Sometimes they present with sudden intense dismissive,
critical, or aggressive reactivity, but the clear underlying reasoning may be
inaccessible for a collaborative exploration in therapy. At other times, they can
demonstrate a remarkable capacity for identifying and relating to others’ states
and intentions, but they may use this primarily for self-enhancing or avoiding
purposes, without reflecting on or understanding the underlying motives. Nev-
ertheless, a compromised or even a lack of emotional self-knowledge (Kramer
& Pascale-Leone, 2018)—an awareness and understanding of one’s own emo-
tions and feelings, and their expressions and meanings in interpersonal and
social contexts—is predominant in patients with PN and NPD.
Patients’ internal processing may be activated and or challenged by
external life experiences that all of a sudden stir up intolerable reactions
that may be difficult to process. An unexpected question or comment from
the therapist may evoke reactions that are grounded in deeply compart-
mentalized emotional experiences and thought patterns. The therapist, in
such situations, is facing various discrepancies or disconnects between the
external and the internal facets of the patient’s mental functioning. These
individual differences and fluctuations in functioning in patients with PN or
NPD further point to multifactorial underpinnings that in various ways can
contribute to individual expressions and variations of narcissistic pathology.
An important aspect of interpersonal functioning in patients with PN or NPD
relates to the balance and interaction between deficits, defensiveness, and
motivation (Mizen, 2014). In addition to the deficits mentioned above, psy-
chogenic defenses have long been considered a major challenge for engaging
06_G4784_449.indd 85 3/11/2020 2:03:03 PM86 RONNINGSTAM
NPD patients in psychotherapy and psychoanalysis (O. F. Kernberg, 2015).
On the other hand, these patients can also be driven by clear and intentional
motivation to avoid or pursue, to compete or protect, and to manipulate or
maneuver (Baskin-Somers, Krusemark, & Ronningstam, 2014). Self-esteem
regulation, with consistent self-enhancement or oscillations between grandios-
ity with grandeur control and vulnerability with inferior insecurity (Pincus,
Cain, & Wright, 2014), is affected by the patients’ internal processing as well
as by their external life context and experiences.
Given this background, internal processing in patients with PN or NPD
is suggested to be specifically influenced by compromised affect tolerance and
processing, identity diffusion, reflective ability and mentalization, sense of
agency with competence and control, self-esteem and perfectionism, and abil-
ity to symbolize. The aim of the following sections is to highlight and discuss
both the separateness and the links between the internal processing and the
external features and patterns in interpersonal relating. Clinical case vignettes
will demonstrate the unfolding connections between the internal processing
and external presentations and interactions.
LIMITED AFFECT TOLERANCE AND
COMPROMISED EMOTION PROCESSING
Patients with PN or NPD have difficulties connecting their own affects and
compatible emotions to verbal formulation and interpersonal/social related-
ness and interactions. In a recent study of processing and verbal elaboration
of affects in patients with NPD features, Bouizegarene and Lecours (2017)
used observer-rated measures and identified a lesser ability to tolerate, verbal-
ize, and mentalize sadness, which causes an inability to experience grief (O. F.
Kernberg, 2010). This study not only indicates the presence of emotional suf-
fering in patients with PN, but also points to the importance of attending to
the complexity of underlying affect processing in assessment and treatment.
Clinical observations have indicated that patients with PN or NPD
can demonstrate outstanding intellectual capacity and elaborative verbal
plasticity, with accompanying ability to provide seemingly rich and detailed,
even emotional descriptions of situations and experiences. This can readily
shield compromised access to more genuine emotions and leave the therapist
with the impression that the patient is more insightful or reflective then he/
she really is. Efforts to empirically conceptualize these differences were first
focusing on the “masking” of inferiority by maintaining a grandiose self-
view (Morf & Rhodewalt, 2001). This mask model was later connected with
fragile self-esteem and the interaction between implicit automatic, uncon-
trollable self-esteem and high overt levels of explicit self-esteem (Marissen,
Brouwer, Hiemstra, & Deen, 2016). Evolving evidence of the co-occurrence
of and fluctuations between grandiosity and vulnerability (Pincus et al., 2014)
gradually connected with theoretical and clinical psychodynamic accounts
on overt and covert narcissism, oscillation between superiority, and control
versus inferiority and powerlessness, and between anger and shame (Akhtar,
1989; Ritter et al., 2014; Ronningstam, 2012).
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Patients’ underlying compromised emotional regulation with hidden
affect and drastic discrepancies between external interaction and internal
processing tend to unfold in the therapeutic alliance. Facing the contrasts
between these patients’ presentation and the rapidly or gradually evolving
countertransference can be challenging but nevertheless very informative for
therapists (Gabbard, 2013; Tanzilli, Colli, Muzi, & Lingiardi, 2015). Patients’
tolerance for mutual interactions and collaborative sharing within the thera-
peutic alliance depend upon the degree of their compromised emotion pro-
cessing as well as on intensity of the emerging internalized object relations.
Sudden disruptions or dropout from treatment can follow.
CASE VIGNETTE
Dora, a woman in her late 20s, had after years of procrastination finally gradu-
ated with top grades from a master’s program. She needed to take a licensing
exam in order to be ready for the next major step in her professional career.
She had gradually benefitted from a few years of individual psychotherapy
that focused on her enhanced self-esteem, perfectionism, fear of failure, entitle-
ment, and ostentatious aspirations. In the middle of this process, the therapist
received a message from Dora that she had decided to end the therapy. The
therapist’s efforts to encourage her to come back or to find out the reasons for
this sudden unexpected ending remained unanswered, and the therapist was
left to her own speculations. A year later, the therapist received a letter from
Dora describing her present successful career track in the profession she’d
aspired to and explaining her earlier need to abruptly stop therapy in order to
pursue her career in finance. She had suddenly found the two commitments—
psychotherapy and her professional career-focused work—totally conflicting
and incompatible, and had felt it necessary to maintain her self-control and
do this transition on her own.
At a couple of scheduled follow-up therapy sessions, Dora explained
further how facing a career with job interviews had escalated extreme internal
anxiety and unusual images of her father who had passed away a few years
earlier. Of the opinion that women should not advance, he had criticized and
undermined her intellectual ability since she was a child, despite the fact that
she was intelligent and got good grades. Dora had been convinced that she
would fail to engage in her professional career if she stayed in therapy. When
the therapist asked, “How come?,” Dora began to cry, saying that she was
not supposed to surpass her father. In her mind, that created a significant
conflict as she, on the one hand, was convinced that she was superior to her
father and knew what she wanted to do, but on the other that she would
be punished for her aspirations. She even associated his passing away with
her advancements. She had felt undeserving of the potential support of her
therapist, and had also at the time felt unable to process this in therapy,
given its immediacy in the context of her job applications and interviews.
She described the experience:
Just thinking about you made me feel overwhelmed by shame and fear—I under-
stand that you are caring and competent, but in my mind you became either
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somebody who wanted to hold my hand which would have been deeply embar-
rassing for me! Why should I have somebody to hold my hand when I am about
to enter a competitive business world? Alternatively, I envisioned that you would
have scorned me for my fear and like my father try to convince me that my feelings
were evidence of my incompetence and potential for failure.
This patient needed to reach a sense of independence and competence,
with stabilized internal and self-regulatory balance, in order to be able to access
her self-reflective processing. This encouraged her to reconnect with her thera-
pist and process the earlier emerging transference and residual psychological
trauma (Maldonado, 2006; Simon, 2002) that was activated when she was
beginning to pursue her professional advancement. At that point, she was able
to form a narrative (Ribeiro et al., 2011) and relate to the therapist, who was
the source and activator of her internalized object relations (O. F. Kernberg,
1976), which a year earlier had resulted in an overwhelmingly intense trans-
ference reaction with accompanying immediate avoidance and withdrawal.
This example raises the question of how and when internal processing
as opposed to external presentation and interpersonal relating can depart
and remain separated or, alternatively, be integrated and processed in the
therapeutic alliance. In other words, how do these contexts interact with and
affect the patient’s ability to reflect and progress? One way is through real-
izations based in real life experiences (Ronningstam, Gunderson, & Lyons,
1995). Another is through realizations gained in the exploratory relational
interactions or emerging transference within the therapeutic alliance. A third
way involves unfolding narratives based on realizations of internal patterns
related to attachment, psychological trauma, and self-regulatory strategies
within the individual him/herself.
IDENTITY DIFFUSION
As mentioned earlier, internal processing can be separated and remain hidden,
or even be inaccessible in patients with PN or NPD. As such, it can contribute
to or reflect identity diffusion, with some intermittent underlying awareness
of counterintuitive or perplexing sense of self with fear of being exposed or
rejected. Focus on self-enhancing achievement and “other orientation” with
the aim of generating specific reactions in others may for a while sustain such
character function.
CASE VIGNETTE
Carl, an outstanding pianist in his early 20s, managed to get his audience’s
attention both through his choice of music and his way of performing. His
parents, especially his mother, were very proud of him and invested a lot in
supporting his education and engagements. He was confident, arrogant, and
self-assertive, and he readily got his peers to feel inferior, especially as he
seemed to have an unquestionable and exceptional musical career in front
06_G4784_449.indd 88 3/11/2020 2:03:03 PMINTERNAL PROCESSING IN PATIENTS WITH NPD 89
of him. When moving to a top conservatory, he suddenly began to feel lost,
stopped rehearsing, stayed in bed, started using cocaine, and began losing his
temper in front of his parents and teachers. Starting treatment, he told his
therapist that for a long time he had felt increasingly conflictual, empty, and
misplaced in his pianist career, despite being very gifted and capable. Since
his early teens, he had also sensed that he really did not know who he was,
what he truly wanted in life, or what he indeed liked to do and was good at
doing. It had felt easy and natural to adhere to his parents’ expectations and
to embrace his ability to please them as well as his teachers, and impress his
peers. He had also really liked receiving the audiences’ acclamations, which
had spurred his self-esteem and steered his attention away from underly-
ing insecurity and self-doubts. However, at the same time, he was not sure
whether he was the one really playing the piano at the concerts or whether
it was somebody he just felt he should be. He also conveyed that he had
secretly discovered he liked and was good at cooking and that one of his
teachers in high school had actually suggested he should apply to restaurant
school. He had found the idea both appealing and totally impossible, as he
foresaw that such a decision would upset and even rupture his relationship
to his parents.
The psychotherapy focused on Carl’s identity and self-esteem, encourag-
ing his self-exploration, with attention to experiences, reactions, and feelings
in his relationships, as well as in his efforts to explore and decide on a new
alternative life track. In addition, he joined a DBT (dialectical behavior train-
ing) group to learn more about emotion regulation, and his parents attended
a parent psychoeducational support group.
For this young man, facing a new stage in life drastically unraveled his
identity diffusion and the underlying processes that had held up one aspect
of himself but ignored other important sides of his developing personality.
This can be challenging to face, especially when actual competence can spur
self-esteem and a sense of superiority. Admiration and rivalry with peers fur-
ther added to this process. Realizing this internal reality and vulnerability
motivated him to begin therapy and search for the more genuine sense of self
and options for his future.
SELF-REFLECTIVE ABILITY AND MENTALIZATION
Reflective ability and mentalization (Fonagy, Gergely, Jurist, & Target, 2002)
in patients with PN or NPD are compromised or fluctuating and can remain
out of reach in treatment (Diamond et al., 2014). Self-reflection encompasses
abilities to identify and connect internal experiences with type and level of
visceral and bodily arousal; to connect thought and feelings in daily life; and
to realize that one’s own perception of interpersonal relationships is subjective
and may differ from external reality (Dimaggio & Lysaker, 2018).
All this influences the patients’ ability to make a direct connection between
their range of internal experiences and their efforts to verbally describe and inter-
actively communicate with the therapist. In addition, it influences the capacity
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for mentalization, that is, attending to interactions between self and others
and understanding oneself and others in terms of intentional mental states
with needs, desires, motivations, and goals (Bateman & Fonagy, 2016; Fonagy
et al., 2002). In a recent study, Nazzaro and colleagues (2017) also verified that
impaired reflective functioning (the operationalization of mentalization assessed
with the Reflective Functioning Scale; Fonagy, Target, Steele, & Steele, 1998)
was strongly associated with cluster B personality pathology and vulnerability
in personality functioning. Failure in reflective ability and mentalization invites
personality pathology, and a focus on mentalization in treatment can lessen
rigidity, promote understanding, and adjust behavior and actions.
It is important to keep in mind that self-reflection with gain of internal
control usually precedes the ability for genuine mentalizing in patients with
NPD. Their tendency for pseudo-mentalizing—demonstrating and pretend-
ing a primarily intellectual capacity to assign intentions and beliefs in others
based on their cognitive empathic ability (Ritter et al., 2011)—can contribute
to misevaluation of their actual internal processing and reflective ability. Other
underpinnings to reflective ability in patients with NPD include co-occurring
alexithymia, the impaired ability or even inability to tolerate, feel, and experi-
ence own emotions (Krystal, 1998) and self-centeredness (Fan et al., 2011). In
addition, patients can fluctuate between preoccupation and distancing, some-
times being totally immersed and preoccupied with a specific issue, other times
remaining ignorant, distant, or dismissive. Intense reactivity and difficulties
integrating and verbalizing emotional experiences also contribute to lack of
reflective ability. As a result, the therapist is facing an unusually complex task
of discerning the obscured and hidden internal processing from the obvious
external reflective and mentalizing interactive patterns.
Attending to experiences in external life context or within multimodal
treatment—combined group and individual therapy focused on improving
patient’s reflective ability—can help reveal such complexities and discrepan-
cies in internal and interpersonal functioning.
CASE VIGNETTE
Laura stormed out of a group therapy session after a heated interaction with
the group leader who had suggested that her critical view of others may reflect
her own self-negativity and insecurity. In her individual session a couple of
days later, Laura described in detail her intense and overwhelming reactions
to the group therapist’s comment: “It felt as if my brain caught fire and my
stomach cramped. . . . I don’t understand why I react so strongly.” The thera-
pist invited further explorations of how Laura perceived and experienced the
group leader’s comment and after a long pause she said:
I felt invaded, as if somebody was trying to overpower and take control over
me. . . . I am embarrassed for reacting so strongly . . . but I just get sooo angry and
scared!! I was not prepared and I felt exposed in front of everybody. It happens to
me at work too. When I presented a project plan in front of my department, one
of the managers began questioning my choice of methods and its impact on the
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potential results, and suggested a totally different strategy. It felt as if I was hit by
a bomb. I thought my project plan was perfect. This is why I got fired from my
previous job and it is one of the major reasons I am in treatment!
A couple of months later, in the context of another intense group interaction,
Laura had gained some more reflective ability for emotion processing and
self-reflection and said:
I can see that I exaggerate what others say to me and how I tend to misperceive
their intentions. I think that is why I react so intensely. As I sit here, I can realize for
instance, that my manager at work actually tried to improve my project proposal
when he questioned my choice of methods. And the same with my group leader.
I have been thinking about what she said about my harsh self-criticism. Maybe if
I can be somewhat more accepting and understanding of myself, I may not have
to be so critical of others, and easily get so suspicious of their intentions and get
ready to attack.
This example demonstrates some of the underpinnings of interpersonal
reactivity in patients with PN or NPD that both echo and influence their
impaired reflective ability—that is, compromised emotional processing, with
visceral internal reactivity, shame-based or shame-covered interpersonal
aggressivity, lack of differentiation of self and others, and need for internal and
interpersonal control. Attending two different treatment modalities, one that
exposes the patient interpersonally and activates narcissistic patterns (group
therapy) and another that provides an alliance that encourages exploration of
internal processing with verbalizing, narration, and self-reflection (individual
psychotherapy) can be very useful for NPD patients.
SENSE OF AGENCY, COMPETENCE,
AND CONTROL
Self-agency or sense of an own agential core conceptualizes the awareness and
ownership of goal setting and direction, and of planning, initiating, execut-
ing, and controlling one’s own thoughts, intentions, actions, and motivations
(APA, 2013, section III; Fonagy et al., 2002; Gallagher, 2012; DSM-5). As a
central aspect of narcissistic functioning, sense of agency influences both self-
regulatory and interpersonal strategies, such as attention seeking, competitive-
ness, and achievements (Campbell & Foster, 2007). The subjective experiences
of fluctuations or loss of agency are especially frightening for narcissistic
individuals whose sense of self-worth is fragile and whose ability for interper-
sonal relationships is compromised (Ronningstam & Baskin-Sommers, 2013).
Capacity for experience of agency in therapy depends on several factors. Knox
(2011) highlighted affect regulation (the ability to experience strong emotions
without fearing them as destructive), self-reflective ability (the awareness of
the mental and emotional separateness of self and others), and regression in
the service of development (the need to create a reaction in the other to be
able to work through and move on).
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CASE VIGNETTE
Amy, a married woman in her mid 30s and mother of two, started therapy as
she considered resuming work after having been a stay-at-home-mom for a
several years. Despite several opportunities, she felt hesitant and found herself
procrastinating. Amy came across as a woman who belonged to the top class
in society. She was extraordinarily well articulated and readily engaged in long,
seemingly convincing descriptive elaborations about herself and her family,
which differed from session to session. Initially, Amy praised her husband
and identified with his career, adored her children, and adamantly repeated
how much she loved her mother. The therapist found this rather incompatible
with her unfolding description of her problems as she expressed increasing
frustration and rage outbursts with regard to her children, and feelings of
envy and inferiority in relation to her successful husband. In addition, she had
vivid images as to what her own success could have been had she not gotten
married and had children. All this furthered her feelings of resentment and
regret. Her efforts to reenter a career had always been postponed as it evoked
increasing self-doubt and insecurity, and she repeatedly asked herself “Why
am I feeling like this?” A sudden decline in her husband’s health required Amy
to take on more financial responsibility for her family. She began to struggle
with intense confusion, self-hatred, and a sense of not knowing who she was
and what she wanted to do with herself. In contrast to while she was grow-
ing up, when she was a top student and athlete, often feeling that she took
care of and protected her parents who had intermittent alcohol problems, she
now found herself in an incomprehensible trap. Further exploration of Amy’s
internal experiences revealed that she also felt dismissed and degraded by her
mother. She had always sensed that she lost in competition with her younger
sister for her mother’s attention, but she consoled herself by believing that
she was admired for her achievements by her father. By perceiving herself
as “taking charge” in her family of origin, she had also been able to justify
or ignore their distancing from her, especially after she got married and had
children. As these realizations gradually unfolded, Amy became overwhelmed
with rage, sadness, and feelings of loss and betrayal. She felt that a fantasy of
her own traction and influence suddenly crumbled, forcing her to face a deep
sense of insecurity, shame, envy, longing, and inadequacy. However, as she
processed this in therapy, she also noticed less frustration and accompany-
ing rage outbursts vis-a-vis her children, and if they occurred, she had better
ability to stop herself and reflect on and assess the situation and see different
perspectives. In addition, she had moments when she could appreciate her
husband’s family by recognizing their genuine support of her, although that
also made her feel uncomfortable and intruded upon. In therapy, she began to
integrate her role and identity as a mother with her professional competence
and aspirations. She struggled with perceiving her therapist on the one hand
as a successful but unattainable and demeaning role model, and on the other
hand as an enviable threat. A few months later, Amy had her first job interview.
Her insecurity and avoidance, with the fear of exposing herself and failing and
the underlying shame, became the new focus in psychotherapy.
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This example demonstrates the unfolding of internal narcissistic pro-
cessing in the context of a major life change, which specifically challenged
the patient’s sense of agency and competence, and evoked intense emotional
reactions. Fragile self-enhancement was interrupted by reactive rage, shame,
and fear of failure. Actual sense of agency and reality-based competence was
shattered in the context of intolerable internalized object relations and accom-
panying compromised emotion processing and tolerance. As the full range
of these experiences was regenerated, the patient’s external life experiences,
internal processing, and transference reactions could begin to be integrated
and processed within the therapeutic alliance.
SELF-ESTEEM AND PERFECTIONISM
Perfectionism has long been associated with NPD (Rothstein, 1980). As an
integral part of narcissistic self-esteem regulation and self-enhancement, per-
fectionism can serve as a means for control as well as for interpersonal com-
petition and dismissiveness in individuals with PN or NPD. In a study of the
relationship between perfectionism and various aspects of neurocognitive
performance, Slade and colleagues (Slade, Coppel, & Townes, 2009) differ-
entiated between positive perfectionism with motivation and focus related
to mental and physical efforts versus negative perfectionism motivated by
fear of failure with focus on avoidance of making errors, especially related
to accuracy and speed. These results are specifically relevant for pathological
narcissism where perfectionism usually is less related to morals and ideals,
but foremost aiming at achieving grandiose standards, maintaining a sense of
self-cohesion, control, and high level of performance, and especially sustain-
ing status and others’ admiration. Often used as a vehicle to avoid humilia-
tion and shame, failure to measure up to perfectionist standards can rapidly
evoke shame, rage, and depression (Marčinko et al., 2014; Sorotzkin, 1985).
In addition, perfectionist standards can also be more directly associated with
an underlying fear of failure.
CASE VIGNETTE
Maria, a woman in her mid 20s who had been in psychotherapy for several
years, outlined training programs and manuals for various sports at work
and also taught their contents. She felt very proud of her accomplishments,
which gave her a sense of professional authority in line with her perfectionist
standards. She had also received significant admiration and acclaim for her
organizational and teaching skills. One day, the director asked her to apply
the manual to preschool children and perform a series of swimming lessons.
She adjusted the manual and entered the first lesson to find seven or eight
kids in the pool, splashing, screaming, and laughing. They were all having a
super-fun time and did not pay any attention to her entering the pool area.
Maria described her reactions in detail: First, she was instantly infuriated and
considered just leaving and complaining to her director. Then she panicked,
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believing that the kids, their parents, and the director were out to prove her
incompetent, and after an additional few seconds she felt totally paralyzed
and convinced that she was going to fail and be fired. For a moment, she
even thought about suicide. However, as she stood there facing these lively,
loud, and laughing kids, she noticed her own bodily sensations and realized
that the kids actually were enjoying themselves. Because of this awareness,
she understood that they were not determined to make her fail. Her paralysis
lifted, and she decided to get into the pool, join the kids, and splash around to
get their attention. Then she introduced herself and started the lesson. She also
realized that she had to put the “perfect” manual and teaching strategies aside
and apply a much more creative, playful, spontaneous, and “kid-appealing”
approach to reach her goal and accomplish her efforts, which initially felt very
uncomfortable and even frightening. However, this realization also enabled
her to organize the lessons and teach the kids how to swim. To her psycho-
therapist, Maria described feeling quite stunned by this experience. For the
first time, she sensed she had found a constructive way out of her initial and
familiar, infuriated, overwhelming, and panicky reactions when facing a chal-
lenging real-life situation. Such situations had usually evoked self-silencing,
withdrawal into self-condemnation, and suicidal ideations.
This patient apparently struggled with extreme fear of not measuring up
to her own perfectionist standards and consequently failing, which externally
tended to trigger superior dismissiveness or aggressive outbursts. Her ability
to redirect her attention to the kids’ laughing and realize both cognitively and
emotionally that they were enjoying themselves made it possible for her to
approach the situation in a new and more proactively competent way.
Perfectionism focused on accuracy and speed (negative perfectionism)
can be useful in certain contexts, such as in individual precision sports like
ice-skating and gymnastics or in concert performances for solo piano or vio-
lin. When combined with positive perfectionism, such negative exact-focused
perfectionism can help optimize performance (Slade et al., 2009). However, in
the context of underlying narcissistic pathology, with self-doubts, sensitivity
to expectations and excessive concerns about mistakes, or detachment from
regular self-criticism, failure to measure up can evoke intense inner agony,
feelings of inadequacy, avoidance, and depression.
CASE VIGNETTE
David was an exceptional gymnast who during high school advanced to com-
pete at the national level; in college, he was considered for the upcoming
Olympic Games. However, in one of his final competitions, David fell for the
first time, sustaining a concussion and broken bones. Although he recovered
medically and resumed physical strength, this event nevertheless led to major
mental problems, including a suicide attempt. A psychiatric evaluation revealed
rather severe narcissistic pathology, including extraordinary aspirations, need
for attention and admiration, feelings of inferiority, extreme self-criticism,
and identity diffusion, and David was referred for psychotherapy. He told his
therapist that since childhood he had relied on his athletic capabilities to feel
worthy, impress his parents, and be accepted by his peers. After the accident,
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however, he had felt increasingly lost, as if he had fallen into a big hole, and
could see no future for himself. He had begun to feel afraid of his gymnastic
activities, unable to trust his capability, and could not identify anything else
that would provide him with a sense of self-worth, attention, and direction.
Initially, he frowned at the prospect of becoming a trainer; he dismissed the
suggestion to pursue alternative activities or academic studies and chose to
isolate himself in his room playing videogames in addition to attending treat-
ment. He remained in intensive multimodal treatment for a year, during which
he gradually tried out different types of temporary jobs and finally decided
to apply for college in another state. He ended treatment when he started
college, but a couple of follow-up sessions indicated that he had continued
psychotherapy and was adjusting well to his college studies and environment.
These two case examples demonstrate the importance of exploring and
identifying the subjective motivation and internal processing related to perfec-
tionism. It also calls for attention to the degree of rigidity and whether and to
what degree the patient’s perfectionism is associated with a sense of identity
and integrated sense of agency in addition to performance.
COMPROMISED ABILITY FOR SYMBOLIZATION
Symbolization, the ability to represent one thing with something else and to
differentiate the symbolized from the original object, requires both affective
and relational competence, the ability to reflect and to access and differenti-
ate between concrete reality and its potential underlying meanings. More
recently, attention has been directed to mental concreteness and desymbolizing
or non-symbolizing in certain patients, especially those with NPD, and to the
impact on alliance building, countertransference, and processing of interpreta-
tions (Bonovitz, 2016; Frosch, 2012). Mizen (2014) in particular suggested an
integrative model which outlines a pathway for narcissistic functioning that
integrates both developmental, neuropsychological, affect, and relational fac-
tors. Accordingly, narcissistic pathology represents “failures at specific points
on a representational function pathway through which subcortical affect and
visceral feelings in a relational context become the basis for abstraction and
language” (p. 254). In other words, this implies an interaction between bio-
logical and relational factors for generating language as a means of commu-
nicating feelings. Biological, relational, or psychogenic factors may disrupt the
development of symbolic functioning, resulting in pathological and narcissistic
interpersonal patterns of relating. Compromised capacity to symbolize leads
to a “concrete” mode of mental functioning with diminished reflective and
mentalizing ability. It leads to compromised awareness and understanding of
own emotions and feelings (Kramer & Pascale-Leone, 2018). When facing
sudden, unexpected, and challenging life circumstances, this can also escalate
sudden acute suicidality, with risk for lethal actions (Ronningstam, Weinberg,
Goldblatt, Schechter, & Herbstman, 2018).
Maldonado (2005) identified the manifestation as a constant verbal act-
ing out in the alliance, that is, a verbal communication that is empty of mean-
ing. This affects alliance building as it can evoke the therapist’s intense negative
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reactions and countertransference. It also prevents a collaborative therapeutic
process from developing, with eminent risk for negative enactments or pre-
mature termination. Symbolization, mentalization, and metacognition are all
associated with the experiences and verbal elaboration of affect (Bouizegarene
& Lecours, 2017; Lecours & Bouchard, 2011).
CASE VIGNETTE
Betsy: My four previous therapists started to behave just like my mother so
I quit immediately. I could not stand it and I could not trust them. And
just so you know—if you start to talk or act like my mother, I will fire
you too. Immediately!!!
Therapist: I don’t intend to deliberately act like your mother, but if you
find that I do remind you of your mother, I would suggest that you
tell me, because it could be a good opportunity for us to talk about
your memories and experiences of your mother that suddenly can be
activated in different situations
Betsy: Well, that is why I need treatment, because my mother was such an
aggressive self-inflated person and I can’t get her out of my mind. I
can’t control her, stop her, or get rid of her, and I am afraid that I will
become like her!
This patient demonstrated concreteness in her thinking and identity dif-
fusion accompanied by aggressivity, blame, and dismissiveness, which auto-
matically were activated when facing her therapists. Difficulties separating the
therapist as a person from her internalized experiences of and relationship to
her mother readily evoked the impression that the patient was developing a
negative transference reaction that calls for the therapist’s transference-focused
interpretation. However, using the concept of transitional space (Winnicott,
1971) concreteness can be a defense or a means to avoid the reexperience of
intense affects or early developmental trauma (Cancelmo, 2009; Maldonado,
2005, 2006). In addition, alexithymia, which involves a deficit in symbolization
of emotional somatic and mental states, can also contribute to concreteness,
especially as it relates to an unawareness of or incapacity to distinguish physi-
cal and affect states, with a lack of words for emotions. Lemche and colleagues
(Lemche, Klann-Delius, Koch, & Joraschky, 2004) identified a connection
between insecure and disorganized attachment and deficits in the development
of internal state language, which implies that alexithymia can be a consequence
of deficits in the developing mentalizing ability. Awareness of and attention
to emotions are particularly important in treatment of patients with PN and
NPD, given the significant role of emotion dysregulation within this range of
pathology. On the other hand, these patients’ hypervigilance and tendencies to
readily feel insecure and criticized when facing difficulties or shortcomings—
that is, an indication of unawareness of own emotions—call for a gradual
collaborative and exploratory therapeutic strategy. When signs of emotions
can be attended to, experienced, and reflected upon, a transition from implicit
to explicit aspects of emotion can be possible through the psychophysiological
activation within the therapeutic alliance, which can link sensory input with
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different memory and symbolizing systems (Baskin-Sommers et al., 2014; Fan
et al., 2011; Krystal, 1998; Lane & Garfield, 2005; Mizen, 2014). A therapeu-
tic frame, and the nonverbal general atmosphere and open attitude that the
therapist can convey, may enable such a gradual transition from concreteness
towards symbolization, gradual verbalization, and interpersonal interaction
within the therapeutic alliance. The use of metaphors (Stine, 2005) can pave
the way for such a link between affect, impulses, and negative concreteness,
towards enhancing the communication and collaboration.
EXTERNAL INDICATIONS OF
INTERNAL PROCESSING
Of importance for assessment of PN and NPD, and especially for connecting
to and understanding the patient, is an awareness of how internal processing
relates to and influences observable features of narcissistic pathology. Table 2
provides an outline for possible connections between the different components
of internal processing and some of the diagnostic features in DSM-5 sections II
and III. Limited affect tolerance can result in need for control and interpersonal
TABLE 2. Interface Between Internal Processing Components
and External Diagnostic NPD Features
Indicators of internal processing Diagnostic features from DSM-5 sections II and III
Limited affect tolerance Need for control and fear of losing control
Avoidant and dismissive interpersonal patterns
Excessive reference to others for self-definition and self-esteem
Identity diffusion
regulation
Often unaware of own motivations
Self-reflective ability and mentalization Self-centeredness
Over- or underestimate of own effect on others
Impaired ability to recognize or identify with the feelings and needs
of others
Interpersonally exploitative, takes advantage of others to achieve
Sense of agency, competence, and control
his/her own ends
Excessive attempts to attract and be the focus of others’ attention
Admiration seeking
Goal setting based on gaining approval from others
Self-esteem and perfectionism Grandiose sense of self-importance
Firmly holding to the belief that one is better than others
Believes he or she is “special” and unique
Relationships largely superficial and exist to serve self-esteem
regulation
Personal standards unreasonably high in order to see oneself as
exceptional, or too low based on sense of entitlement
Inflation or deflation of self-esteem
Compromised ability for symbolization Mutuality constrained by little genuine interest in others
Self-centeredness
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