John shows signs of a narcissistic character disturbance and such people often complain of low or dysthymic states. New research gives us a deeper and more detailed view of those whose personality is organized around narcissistic issues (Russ E et al, Am J Psychiatry 2008;165: 1473-81). Researchers used patients from a random sample of experienced practitioners employing several assessment instruments. People with character difficulties can have overlapping problems, such as chronic feelings of sadness. Investigators wanted to identify distinctive elements of narcissistic individuals. They found 2 key features: interpersonal vulnerability, in which the patient feels

• misunderstood
• fears rejection or abandonment
• tends to have extreme reactions to perceived slights or criticism

The other feature was chronic underlying emotional distress, with tendencies to feel

• unhappy
• despondent
• hostile
• anxious

Other facets included

• difficulty regulating affects,
• being competitive rather than cooperative with others
• having a tendency to externalize blame

Many narcissistic people treat others as an audience to witness their own self-perceived brilliance. Keep in mind that when you encounter this, it is indeed pathognomonic, but not all narcissistic types will interact in this way. Problems with empathy are common, although not limited to narcissistic characters. Previous work to define character disorders has relied on patient reports, which are understandably limited by the degree of self-awareness of the subjects. By using the observations of clinicians who knew these patients well, however, a clearer portrait of narcissistically disturbed people emerges.

This study identified the following three types of narcissistic characters.

• Grandiose/malignant narcissists are “takers,” who exploit others with little regard for their welfare. These individuals suffer from few doubts or underlying feelings of inadequacy.

• Fragile narcissists can be grandiose, often quietly, but are also markedly insecure. Their inner world fluctuates between feeling inflated and inadequate and they can flip back and forth rapidly between these two states. They may become more grandiose when they feel threatened. They have difficulty feeling vulnerable without devaluing others.

• High-functioning/exhibitionistic narcissists have inflated self-esteem and are competitive and attention seeking. They can be provocative and sexually seductive. They often have notable strengths: they can be confident interpersonally, accomplished and articulate. Because of impaired empathic capacity, their relationships may have an empty quality, which leads them to become bored.

This work shows that narcissism is much more complex than is currently reflected in DSM IV, which only describes the grandiose/malignant group. It suggests that the core experiences of pain, inadequacy, vulnerability and rage can present in three different subtypes of narcissistic character that can appear quite different from each other on the surface. This work tends to confirm the clinical lore that though the DSM IV describes the loud, overt narcissist, there is a significant group of more ‘quiet’ narcissists, who suffer in a similar way at their core.

John’s treatment

Many of John’s problems derived from his “fragile” narcissistic character. He was encouraged to enter psychodynamic therapy with the expectation that he would need to persevere for a long time before lasting change could be achieved.