Empathy in narcissistic personality disorder: From clinical and empirical perspectives.

Abstract

Narcissistic personality disorder (NPD) is associated with an assortment of characteristics that undermine interpersonal functioning. A lack of empathy is often cited as the primary distinguishing feature of NPD. However, clinical presentations of NPD suggest that empathy is not simply deficient in these individuals, but dysfunctional and subject to a diverse set of motivational and situational factors. Consistent with this presentation, research illustrates that empathy is multidimensional, involving 2 distinct emotional and cognitive processes associated with a capacity to respectively understand and respond to others’ mental and affective states. The goal of this practice review is to bridge the gap between our psychobiological understanding of empathy and its clinical manifestations in NPD. We present 3 case studies highlighting the variability in empathic functioning in people with NPD. Additionally, we summarize the literature on empathy and NPD, which largely associates this disorder with deficient emotional empathy, and dysfunctional rather than deficient cognitive empathy. Because this research is limited, we also present empathy-based findings for related syndromes (borderline and psychopathy). Given the complexity of narcissism and empathy, we propose that multiple relationships can exist between these constructs. Ultimately, by recognizing the multifaceted relationship between empathy and narcissism, and moving away from an all or nothing belief that those with NPD simply lack empathy, therapists may better understand narcissistic patients’ behavior and motivational structure.

Internal Processing in Patients With Pathological Narcissism or Narcissistic Personality Disorder: Implications for Alliance Building and Therapeutic Strategies

“…In addition to the deficits mentioned above, psychogenic defenses have long been considered a major challenge for engaging 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 grandiosity 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.…”

“…On the other hand, these patients' hypervigilance and tendencies to readily feel insecure and criticized when facing difficulties or shortcomingsthat 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 different memory and symbolizing systems (Baskin-Sommers et al, 2014;Fan et al, 2011;Krystal, 1998;Lane & Garfield, 2005;Mizen, 2014). A therapeutic 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.…”

Personality Disorders, Attachment and Psychodynamic Psychotherapy

“…Consistent with a model of higher reliance on SR empathy and lower access to more mature, MSA-based empathic responses, patients with BPD had high levels of alexithymia, more difficulty identifying their own emotions than patients with avoidant personality disorder, and reported higher empathic distress and poorer ability to take the perspective of others. In contrast to the findings in borderline disorders, narcissistic disorders show far less impairment in cognitive empathy, particularly in theory of mind tasks, but demonstrate more impairment in emotional empathy, bearing some similarity to the pattern noted in psychopathic individuals in whom experimental tasks requiring cognitive empathy are unimpaired, but who show little autonomic response to another's distress [47]. Thus, the two types of empathy can be dissociated in pathological populations.…”

Dissociating Profiles of Social Cognitive Disturbances Between Mixed Personality and Anxiety Disorder

“…We observed comparable expressions of affective empathy among all clinical and non-clinical groups in both the self-report and performance-based measures. Although this may be surprising at first glance, inconsistencies in the existing literature suggest that any impairments to empathic expression are subtle, complex, and highly variable; while some studies report disturbances to affective but preserved cognitive empathy (Ritter et al, 2011), others have found the opposite pattern (Cain et al, 2015) or highlight the remarkable heterogeneity present even within discrete diagnostic groups (Baskin-Sommers et al, 2014). Both clinical groups reported significantly higher personal distress when empathizing, however, indicating disruption to the process through which we attribute the source of one's own emotional state to the target of our empathic expression.…”

“…Research into these socio-cognitive abilities in PD have begun to reveal impairments in many diagnostic groups. This includes disturbances in the discrimination of emotional facial expressions in Narcissistic (Marissen et al, 2012), Antisocial (Zhang et al, 2016) and Borderline PD (Berenson et al, 2018); reduced imitative control in Borderline PD (Hauschild et al, 2018); an inability to accurately infer the mental states of others in Narcissistic (Bilotta et al, 2018) and Avoidant PD (Moroni et al, 2016); subtle alterations in empathic awareness and expression in Obsessive-Compulsive (Cain et al, 2015) and Narcissistic PD (Baskin-Sommers et al, 2014); and differential patterns of dysfunctional emotion regulation among all Cluster A, B and C diagnoses (Borges and Naugle, 2017; for reviews on social cognition, see Herpertz and Bertsch, 2014;Cotter et al, 2018). Interestingly, in Borderline PD these impairments have been attributed to dysfunctional self-other distinction (Beeney et al, 2016).…”