Will narcissistic sociopaths fake medical problems?

Narcissistic Personality Disorder: A Disease with Many Facets

Patients with narcissistic personality disorder usually present to therapists for comorbid disorders. They are often self-destructive, prone to breaking relationships and attempting suicide.

Narcissism attracts interest because there is evidence that the percentage of narcissists in the population is increasing. Most of the time, however, this is about subclinical narcissism. The pathological form, narcissistic personality disorder, receives far less attention. One reason for this could be that it is not considered to be widespread, and another is that it is relatively seldom investigated empirically.

According to DSM-IV-TR or DSM-5, there are the following criteria for a narcissistic personality disorder: Those affected have a grandiose feeling of their own importance, they demand excessive admiration, they idealize themselves and are strong on fantasies of unlimited success, power, glamor or taken in beauty. They believe that they are special and unique and that they can only be understood by other exceptional or respected persons or institutions or that they can only interact with them. In addition, they show an offensive sense of entitlement and expect to be given preferential treatment.

Exploitant tendencies and lack of empathy

In interpersonal relationships, they are often exploitative and, for example, take advantage of other people in order to achieve their own goals. They also lack empathy, which means that they are unwilling or unable to recognize or identify with the feelings and needs of others. In addition, they are often jealous of others or think others are jealous of them. They are arrogant when dealing with others. At least five of these criteria must be met in order to be able to make the diagnosis.

Current research suggests that narcissistic personality disorder has more facets than those listed. For example, while the DSM-5 assumes a high (grandiose) self-esteem, a current study by German psychologists around Aline Vater from the Charité - Universitätsmedizin Berlin shows that those affected have a lower self-esteem than healthy control persons. The American psychiatrist Elsa Ronningstam from Harvard Medical School in Belmont (USA) also points out that those affected can not only appear self-indulgent and cocky, but also insecure, shy, depressed and over-sensitive. At first glance, this doesn't seem to go together. According to Ronningstam, however, such facets of the disorder also serve to make those affected feel superior and to stabilize themselves psychologically. Furthermore, the narcissistic personality disorder was partially redesigned in DSM-5 (Section III), for example by assigning not only grandiose, but also vulnerable characteristics to it. Recent findings and developments like this suggest that research into the disorder is far from complete.

Patients with narcissistic personality disorder are considered difficult people and unpopular patients. They suffer from their disorder, but also cause a lot of suffering in others. Those affected are difficult in dealing with other people (according to DSM-5), among other things, because they constantly demand attention and admiration, but do not allow this to be passed on to others. They devalue others and are often arrogant. They always want to be the center of attention, but are unable to empathize with others and identify with them. They only take note of the needs and feelings of other people if they are relevant to themselves. You are unable to develop deep and lasting relationships. They have no genuine interest in others and only use them to achieve their own goals.

Because of comorbid disorders in therapy

These characteristics do not make it easy to deal with those affected - nevertheless they are often attractive and their nature is even successful in certain areas of life, for example in management positions. A lack of friendships, isolation and other disadvantages can often compensate for many of them for a long time. Only serious crises and high levels of suffering lead them to therapy, where they are usually presented and treated for comorbid disorders.

The characteristics of the disease are also revealed in therapy, so that therapists must expect to be treated arrogantly and derogatory. The patients are also self-destructive and prone to breakups and suicide attempts. They suppress dependency needs, make it more difficult to establish a therapeutic working alliance and show antisocial traits. In addition, they often see their behavior as appropriate and are therefore difficult to motivate to change. This presents therapists with special challenges.

There are a variety of therapeutic approaches (for example psychoanalytic or dialectical-behavioral) to treat narcissistic personality disorder. However, so far no empirical-scientific studies on the psychotherapy of narcissistic patients have been published, which is why the psychologist Vater says: "The basics of a specific psychotherapy are not clear from a scientific point of view." Nonetheless, different therapy goals can be found in the literature across schools, such as an improvement the ability to relate and flexibility, a reduction in narcissistic behavior or the activation of helpful resources. Techniques that promote the patient's insight into the function of narcissistic behaviors and realistic self-perception, or that contribute to building stable social bonds or regulating emotions, should also be taught. In addition, the therapist should not react with resistance and withdrawal, but without judgment and appreciation. The patient's increased risk of suicide should be taken into account in every treatment.

Dr. phil. Marion Sonnenmoser

Ronningstam E: Narcissistic personality disorder: A clinical perspective. Journal of Psychiatric Practice 2011; 17 (2): 89-99.
Father A, Roepke S, Ritter K, Lammers CH: Narcissistic personality disorder. Research, diagnosis and psychotherapy. Psychotherapist 2013; 58 (6): 599-615.