Journal of Child and Adolescent Behavior
Open Access

Understanding pathological narcissism

Diagnostic and Statistical Manual of Mental Disorders standardizes the signs and symptoms of narcissism in a narrowhomogenous definition. According to DSM-5 people with Narcissistic Personality Disorder usually display 5 or more of these symptoms: grandiosity, fantasy of power, high self-perception, need for continual admiration, sense of entitlement, exploitative-ness, unwillingness to empathize, intensely envious of others and false belief of others being equally envious of them, pompous and arrogant demeanor. While some of these symptoms may be present in children and adolescents, greater frequency, intensity and duration of these symptoms are indicative of pathological narcissism present in around 1% of the population [1].

Clinical, theoretical, and empirical findings over the decade illuminate pathological narcissism as an amalgam of grandiosity, vulnerability, and interpersonal antagonism in around 69% of the respondents. Such individuals display maladaptive attitudes (perfection, dependency, depressive symptoms) to regulate “false self”. Studies also describe the presence of vulnerability as hypersensitivity, insecurity, rage, devaluation, and victimhood. This development of false self in narcissistic individuals often gives rise to emotional and psychic withdrawal upon perceived challenge to authority to counteract fears of abandonment [2].

Statistical analysis from previous studies on Narcissistic Personality Disorder (NPD) demonstrates the prevalence of NPD amongst respondents with other personality disorders to be 20.2%, with rates greater in men (23.0%) than women (17.4%). Correlations with other personality disorders include bipolar I disorder (20.1%),

specific phobia (27.4%), PTSD (25.7%), alcohol dependence (30.6%) and borderline personality disorder (37.0%). Mild association with schizophrenia has also been reported by psychiatrists and psychotherapists. These findings highlight the importance of controlling NPD and associated psychiatrist disorders that are highly comorbid with each other [3].

Few studies have also probed the impact on individuals sharing close ties with pathological narcissists. Grief, burden, mental health, and coping styles were analyzed in 683 participants (romantic partners (77.8%), mothers (8.5%) or other family members (10.0%)) and the findings suggested significant interpersonal impact as depression was noted in 69% and anxiety disorders in 82% of the sample. However, the need for future clinical, epidemiological, and genetically informed studies persists to better understand NPD [4].

This literature review identifies the causes of pathological narcissism in light of available studies (systemic reviews, literature reviews, narrative reviews, and meta-analysis), psychoanalytic theories, online blogs and articles by psychologist, psychiatrists, psychotherapists and victims of narcissistic abuse.

Population

Two population categories, early childhood (3-8 yrs) and early adulthood (20-40 yrs) have been addressed in this review. The primary reason for this was that early childhood is characterized by physical, cognitive, social, and emotional development of an individual; thus, experiences at this age play a significant role in personality development. On the contrary, in early adulthood relativistic thinking enables young people to acknowledge complexities of life and build relationships [5-7].

Search strategy

An extensive literature review was conducted on PubMed, Research Gate, National Center for Biotechnological Information and Psychology Today using search strings: (“Child” OR “Pediatric”) OR “Adult”) AND (“Pathological Narcissism” OR “Narcissistic Personality Disorder”) AND(“Parental neglect” OR “Childhood neglect”) AND (“Grey Matter NPD” OR “Grey matter abnormalities in NPD”) AND (“Personality development”) AND (“psychotherapy”). All the articles were downloaded in Mendeley Reference Manager and non-duplicate articles were screened [8-10].

Selection criteria

Inclusion:

• All the articles defining pathological narcissism were included.

• All the articles addressing unhealthy parenting and NPD were included.

• All stats for association of NPD with other mental health problems were included.

• Articles and blogs generated by google search for mentioned keywords were used to increase depth of review.

Exclusion: All articles addressing pathological narcissism considering generalized mental disorders or cluster B personality disorders were excluded.

Outcomes: Causes of narcissistic personality disorder range in multiple dimensions from pathophysiological changes in brain’s grey matter and genetic predisposition to emotional abuse and parental neglect from caregivers [11].

Causes of pathological narcissism: As differential psychology emphasizes the ways in which individuals differ in their behaviors and processes that underlie it, risk factors for pathological narcissism are complex and varied. However, studies have been able to link biological and psychosocial influences on the manifestation of pathological narcissism.

Pathophysiology

A study by Carz Schulez and colleagues compared Grey Matter (GM) volumes of narcissists to global brain tissue volumes. On magnetic imaging significant reduction was noted in left anterior insular regions, bilateral superior and middle frontal gyrus. The brain analysis also showed smaller GM volume in the fronto-paralimbic brain compromising the rostral and median cingulate cortex. This folded GM plays a crucial role not only in conscious awareness and empathy but also assists thinking and reasoning [12].

Maltreatment may permanently damage certain brain regions, as these broken children grow up to live devastating lives. Brain scans yielded damaged hippocampus (role in learning and memory formation) and amygdala (control of emotions). Overstimulation shrinks the hippocampus and amygdala, adversely affecting the narcissists’ abilities to handle emotions, build healthy relationships and recognize their true self (The Neuroscience of Narcissism and Narcissistic Abuse | CPTSDfoundation.Org, n.d.).

Genetics

Several behavioural genetic methodologies have linked neurotransmitter pathways especially in the serotonergic and dopaminergic systems to personality disorders. A total of 304 pairs of twins in China completed the Narcissistic Grandiosity Scale and Psychological Entitlement Scale; the findings of which suggest biological vulnerability. Grandiosity (23%) and entitlement (35%) heritable. However, holistic review of other non-environmental influences encourages us to keep both the interpersonal and intrapersonal dimensions of narcissism in consideration (Figure 1).

Figure 1. Path diagram illustrating the bivariate genetic model.

Psycho-social

Parental Neglect and Emotional Abuse: Neglect is the absence of support and could be categorized into 4 primary types (physical, medical, educational, and emotional) (What Are the 4 Types of Child Dur E Najaf, et al. J Child Adolesc Behav, Volume 9:5, 2021 Page 2 of 4 Neglect? n.d.). Emotional regulation via primary caregiver’s mirroring of child’s activities and achievements enables the child to recognize personhood (Rees, 2008). Faulty parental empathy and lack of enthusiastic audience imposes the threat of self-regulation to these children at an early age. Neglected children display varying symptoms for self-protection: difficulty trusting, low self-esteem, hypervigilance, emotional reactivity, dissociation, withdrawal, highly impulsive decision making (The Hidden Trauma of Neglect in the Narcissistic Family-n.d) [13].

Unreliable and unpredictable behaviors from parents also nurture narcissistic individuals, who have reported cold spiteful treatment by parents followed by appreciation of any talent e.g beauty, intelligence, wit, humor which frames extreme sense of grandiosity. Constant neglect makes these children empty, frightened, and angry as they set the guard high to hide inner conflicts (How a Child Can Become a Narcissist | Psychology Today, n.d.).

Freud’s view: Freud’s view on narcissism builds on his theory of love humbling human beings. By giving love, the amount of energy expended on ourselves is diminished and balance between autoerotism and object love is reached. However, the lack of admiration by caretakers generates no need for reciprocation, allowing self-absorption. These people might start fantasizing to an extent of becoming delusional.

Narcissistic caregiver

The construction of a child’s identity is highly dependent on the parent's projection. Narcissistic parenting is transactional, so children quickly learn to show excessive gratitude towards basic needs due to little expectations and self-worth. These parents may look at their children as “accessories” with no fundamental sense of responsibility and duty towards their offspring. Too many expectations, excessive praise for good deeds and excessive criticism for ill behaviors leave these children in a cognitive dissonance. Self-love and controlling behaviors constitute a parenting that is highly meddlesome in some ways and completely ignorant in others. Devaluing, silent treatment, projection and blaming are coercive measures to enforce compliance. Children thriving in a narcissistic environment live in a permanent state of fear and anxiety, so they may emerge as perfectionists to gain approval of self-involved caregivers. Narcissism is an inner conflict of identity, as individuals swing between grandiosity and vulnerability; hence, any environmental trigger reminiscing this dark upbringing later in life may bring about impulsive decisions, rage, and withdrawal [14,15].

Present literature reveals NPD to be an outcome of a combination of biological, psychological, and social factors as personality development occurs in relation to genes, environment, and geneenvironment interaction. Humanistic psychology views elements of personality traits in relation to a wider system including cultural, societal, and interpersonal relations. However, not enough literature is available to fully understand NPD, therefore, incorporation of extensive research and expertise to present a set of solutions for both the prevention and treatment of NPD is necessitated.

Conventional use of psychotherapy for mental disorders has an overall success rate of 64% at termination and 55% at follow-up for moderate to mixed pathologies. However, treating narcissism has been a challenge for psychotherapists as these individuals usually steer the conversation towards themselves. Proficient therapists must build the therapeutic alliance to identify the defenses and underlying triggers, enabling these broken children to mend themselves. If clinicians and mental health agencies work in collaboration, optimum mental health of individuals from all ages, ethnicities and backgrounds can be ensured.

Consent for publication: Not applicable

Competing interests: All authors report no competing interest.

Funding: All authors affirm that no funding was used for the conduction of this study