Linking psychoanalytic studies with neuroscience has proven increasingly productive for identifying and understanding personality functioning. This article focuses on pathological narcissism and narcissistic personality disorder NPDwith the aim of exploring two clinically relevant aspects of narcissistic functioning also recognized in psychoanalysis: Evidence from neuroscientific studies of related conditions, such as psychopathy, suggests links between affective and cognitive functioning that can influence the sense of self-agency and narcissistic
Self defeating behavior narcissists and sexual dysfunction. Attention can play a crucial role in moderating fear and self-regulatory deficits, and the interaction between experience and emotion can be central for decision-making.
In this review we will explore fear as a motivating factor in narcissistic personality functioning, and the impact fear may have on decision-making in people with pathological narcissism and NPD. Understanding the processes and neurological underpinnings of fear and decision-making can potentially influence both the diagnosis and treatment of NPD.
Narcissistic personality disorder NPD has its roots in nearly a century of psychoanalytic studies.
Kernberg's 12 and Kohut's 34 groundbreaking efforts to organize psychoanalytic theory and Self defeating behavior narcissists and sexual dysfunction studies into comprehensive descriptions and treatment strategies moved NPD towards recognition as a separate personality disorder. In the Diagnostic and Statistical Manual of Mental Disorders DSM -IV, 56 NPD has been characterized as a pervasive pattern of grandiosity, need for admiration, and lack of empathy, with interpersonal entitlement, exploitativeness, arrogance, and envy.
Other notable phenotypic characteristics include interpersonal distancing and
Self defeating behavior narcissists and sexual dysfunction, insecurity and vulnerability, hypersensitivity, aggressivity,
Self defeating behavior narcissists and sexual dysfunction proneness to shame. The transformation of NPD into a DSM diagnostic category in 10 required significant adjustments and narrowing of extensive clinical observations.
Several components and characteristics of narcissistic personalitypathology that were central in the psychoanalytic conceptualization of narcissism and NPD were left aside in the final choice and formulation of the diagnostic trait criteria. One such characteristic relates to the process and feeling of fear, frequently acknowledged in psychoanalytic studies as a significant part of narcissistic pathology.
Freud 11 noted narcissistic mortification as intense fear associated with narcissistic injury and humiliation. He also observed the shocking reaction when individuals face the discrepancy between an endorsed or ideal view of the self and a drastically contrasting realization. Fiscalini 14 emphasized fear of autonomy in narcissistic interpersonal relations, and Kohut 415 pointed to fear associated with rejection, isolation, and loss of contact with reality, and loss of admiration, equilibrium, and important objects.
Recently, Horowitz 16 highlighted fear in the context of wishes and defenses, and Kernberg 17
Self defeating behavior narcissists and sexual dysfunction 19 has referred to the unfolding of underlying fear in treatment of people NPD, including fear of dependency and destroying the relationship with the analyst, fear of retaliation, of one's own aggression and destructiveness, and fear of death.
Maldonado 20 identified the narcissistic intrapsychic trauma caused by the loss of a bond with a good object associated with ideals and meaning. Such a trauma Self defeating behavior narcissists and sexual dysfunction the individual's sense of continuity, coherence, stability, and wellbeing.
In the Self defeating behavior narcissists and sexual dysfunction balance between repairing such traumas and working through conflicts, reactivations of fear inevitably occur, especially in the context of aggression and shame. An additional limitation in DSM is the absence of diagnostically specified levels of personality functioning. Narcissism ranges from healthy and proactive to pathological and malignant. Consequently, pathological narcissism and NPD often co-occur with consistent or intermittent areas and periods of high functioning, 21
Self defeating behavior narcissists and sexual dysfunction areas or periods of real competence and qualities, as well as cognitive, emotional, and interpersonal capabilities, and social skills.
In clinical and social psychological reports, identification of narcissistic character pathology takes into consideration the functional aspects of shifts between selfenhancement and self -deflation, with intermittent periods and areas of competent functioning.
Dimensions of character functioning that enable such evaluation include selfagency 22 - 25 and self-directedness. Decision-making, a central component in self -regulatory and self-directing efforts, has gained attention in psychoanalytic studies, and recently also in social psychological studies of narcissism. In order to advance our understanding of the different components operating in pathological narcissism and NPD it is necessary to further connect and integrate the psychoanalytic and clinical, as well as the social psychological,
Self defeating behavior narcissists and sexual dysfunction of the disorder.
One unifying approach may be to examine the neural underpinnings in narcissism as a way to refine its phenotype. Research on empathy and empathic functioning has alreadyproven such a link to be most constructive and informative for NPD, 27 - 29 contributing to a significant change in identifying empathy, not as absent or present, but as a multifactorial and fluctuating capability.
The aim of this paper is to further identify possible links between the psychoanalytic perspective on pathological and NPD, and neuroscientific research on narcissism and related pathologies. In this review, we will focus primarily on fear, as it has been considered a central and even a motivating factor in narcissistic personality functioning in psychoanalytic and clinical studies. Further, we will explore the impact that fear may have on decision-making.
Fear is generally considered to be an emotional state, a psychological and psychophysiological response to perceived or anticipated threats or danger. Fear can often serve as adaptive alert and survival mechanism. As such, it represents an ability to recognize danger and an urge to either confront or to avoid or escape, but fear can also in extreme situations cause paralysis and inability to protect oneself. Fear differs anxiety as it Self defeating behavior narcissists and sexual dysfunction a response to real threats, a frightening object, event, or experience, while anxiety is considered an anticipatory warning signal, related to the expectation of unreal or imagined danger, including intrapsychic, unconscious conflicts and erotic feelings.
Fear of not measuring up and falling short can be triggered in specific situations, ie, in the context of evaluation, performance, or exposure. Such fear differs from the more complex or ambiguous fear that in
Self defeating behavior narcissists and sexual dysfunction same way can threaten self-esteem, ie, fear of being overwhelmed, and facing success Self defeating behavior narcissists and sexual dysfunction relationships and intimacy, feelings of shame or guilt, and experiencing loss of control.
Intense overwhelming affect, independently of whether the cause is external or internal, can also in itself be terrifying as it may challenge the individual's sense of internal control. Fear can also become maladaptive or pathological, as such feelings, generated from an initial fear-provoking event, persist and have a negative effect on day-to-day behavior. Experiences in the present are linked to disorganized and fragmented memories of earlier mortifying or traumatic experiences.
Sensory and emotional experiences associated with such early trauma 39 also contribute to the subjective perception and interpretation of a present event as traumatic, ie, retraumatizing. In general, these studies indicate that people who are afraid of failing can be motivated or even susceptible to either invest greater efforts in a task after being exposed to failure information, or to completely avoid such efforts. Fear related to self-esteem regulation and risk of falling short can underlie and motivate a range of behavior in narcissistic personality disorder.
High achievements can be motivated by fear of incompetence and failure; selfenhancement by fear of worthlessness and inferiority; perfectionism by fear of shame and self-criticism; pursuit of special affiliations by fear of losing status or influence; interpersonal ignorance and distancing by fear of humiliation, or being overpowered and lose control; and avoidance by fear of shame and exposure.
These studies and observations raise several questions about the interaction between identifying, processing, and controlling fear from the perspective of narcissistic self-regulation.
So far, studies have shown that people with high narcissism but not meeting criteria for NPD present with higher degree alexithymia, ie, difficulties assessing own and other's emotions. Over the last several decades there has been significant growth in the understanding of the neurobiological basis of fear. At the center of the fear circuitry is the amygdala.
Our nuanced understanding of this complex neural network results from imaging eg, during fear conditioning studiesphysiological eg, skin conductance, eye-blink responseand psychopharmacological studies that not only enhance the mechanistic understanding of fear but also highlight the role of fearrelated dysfunction in the generation and maintenance of various forms of psychopathology. Failure to properly regulate fear responses is central to specific phobia, post-traumatic stress disorder, generalized anxiety, and some Axis II disorders ie, fear of separation Self defeating behavior narcissists and sexual dysfunction loss of support in dependent personality disorder DPD of abandonment in borderline personality disorder BPDand of criticism, disapproval, and rejection in avoidant personality disorder APD.
Studies on the relationship between fear and narcissism have been sparse, both at a phenotypic and mechanism level. One study of individuals with narcissistic traits, as measured by the Narcissism Personality Inventory NPI 49 reported that they display diminished electrodermal reactivity to stimuli, 50 indicating weak responses to punishment or aversive cues.
Despite the limited research directly examining fear and narcissism, there are studies of other related conditions with relevance to pathological narcissism that highlight the importance of fear in the expression of psychopathology. Specifically, the role of fear in psychopathy-related disinhibition has been the focus of studies for decades.
NPD and psychopathy are considered to be overlapping constructs, both expressing symptoms of grandiosity, compromised empathic functioning, and callousness. In fact, Kernberg 2 suggested that narcissism might be the core of psychopathy. Affective deficits in psychopathy have most often been understood in the context of the low-fear model.
Self defeating behavior narcissists and sexual dysfunction, results from imaging studies focused on the amygdala are ambiguous. Other research indicates that the amygdala is hyper-reactive when psychopaths view certain emotionally salient scenes. One explanation for the inconsistent nature of psychopathy-related fear deficits may involve an abnormality in attentional processes. Developments in neuroscience indicate that the function of
Self defeating behavior narcissists and sexual dysfunction amygdala is more complex than just fear processing, and likely plays a significant role in attention and in detecting relevance.
This difficulty balancing demands to process goal-directed and peripheral information creates a bias whereby psychopaths are unresponsive to information unless it is a central aspect of their goal-directed focus of attention.
An important implication of the response modulation hypothesis is that the emotion deficit of psychopathic individuals varies as a function of attentional focus. A recent experiment by Newman et al 60 involving fearpotentiated startle FPS provides striking support for this hypothesis. Of existing evidence suggests that FPS is generated via the amygdala. The results provided no evidence of a psychopathy-related deficit in FPS under conditions that focused attention on the threat-relevant dimension.
However, psychopathy scores were significantly and inversely related to FPS under conditions that required participants Self defeating behavior narcissists and sexual dysfunction focus
Self defeating behavior narcissists and sexual dysfunction a threat-irrelevant dimension of stimuli ie, when threat cues were peripheral.
In a follow-up study, Baskin-Sommers and colleagues 59 specified this attentional-mediated abnormality in a new sample of offenders by measuring FPS in four conditions that crossed attentional focus threat versus alternative focus with early versus late presentation of goal-relevant cues.
First, the authors replicated the key findings reported by Newman et al More specifically, the psychopathic deficit in FPS was only apparent in the early alternative focus condition, in which threat cues were presented after the alternative goal-directed focus was already established.
These results confirm the idea that attention moderates the fearlessness of psychopathic individuals and, moreover, implicate an early attention bottleneck as a proximal mechanism for deficient response modulation in psychopathy see ref 71 for discussion of the bottleneck.
Additionally, Larson and colleagues unpublished data recently completed an imaging study using this paradigm with an independent sample of inmates. Results indicated that decreased amygdala activation in psychopathic offenders occurred only during the early alternative focus condition. Under this condition, psychopaths also exhibited greater activation in selective attention regions of the lateral prefrontal cortex LPFC than nonpsychopaths, and this increased LPFC activation was associated with decreased amygdala activation.
In contrast, when explicitly attending to threat, amygdala activation in psychopaths did not differ from nonpsychopaths. This pattern of amygdala activation closely parallels results for FPS and, Self defeating behavior narcissists and sexual dysfunction, highlights the potential role of LPFC in mediating the failure of psychopathic individuals to process emotion and other important information when it is peripheral to the primary focus of goal-directed attention.
Overall, it appears that psychopathic individuals do ignore fear-related information, but only in the service of focusing on a Self defeating behavior narcissists and sexual dysfunction goal. For example, such an inflexible focus on personal goals may underlie the selfcentered, callous traits associated with psychopathy and may leave psychopathic individuals oblivious to the potentially devastating consequences of their behavior.
While one relationship between and psychopathology is related to deficient fear processing, another relationship between fear and psychopathology is related to over-reactivity to fear.
Specifically, research on other forms of externalizing psychopathology, borderline personality disorder, report increased FPS during instructed fear conditioning 72 and increased amygdala activity while viewing emotional slides. Although this neuroscientific overview applies to near neighbor psychopathologies, several findings introduce possible links to fear processing in pathological narcissism and NPD.
Similar to people with psychopathy, focused attention on goals, such as ambitions, competition, and aspirations, and even on risk-taking efforts, may, for some people with pathological narcissism and NPD, enable ignorance of fear and serve as a fear modulator. The narcissistic individual's awareness is then directed away from potential triggers of feelings of fear and towards more securing or rewarding self-enhancing experiences. It is also possible that when people with pathological narcissism or NPD have to face fear without the possibilities of engaging in avoiding, goal-directed, or self-enhancing strategies, the experience becomes overwhelming and consuming, forcing drastic decisions with seemingly immediate short-term gains.
Further research is needed to parse these possibilities. One Self defeating behavior narcissists and sexual dysfunction for understanding Self defeating behavior narcissists and sexual dysfunction role of fear in narcissism is to examine its impact on functionality, in processes such as decision-making.
Psychoanalytic studies have primarily attended to intrapsychic aspects of decision making.
Identified as a secondary ego process linked between motivation and action, the unconscious courses involved in decision-making have nevertheless been a prime focus of interest. Fear can influence decision-making by engulfing either an individual's sense of agency or sense of identity, or both.
The former can affect competence, while the latter can cause self-confusion and uncertainty about who one really is. Although not currently acknowledged as a diagnostic or clinical indicator of NPD, nevertheless, remarkable lapses in some narcissistic individuals' decisions can force them into
Self defeating behavior narcissists and sexual dysfunction situations and life crises that call for urgent need of intensive treatment.
Sometimes such lapses can have devastating consequences, including suicide. Usually referred to either as narcissistic crises or trauma motivated by urgent, defensive push for protection and enhancement of self-esteem, or by avoidance of perceived inevitable ultimatums, many of the roots and underpinnings for such decision-making are still relatively unknown.
As with fear, there is an important normal aspect of decision-making, especially its role in self-esteem regulation and sense of control, that contributes to an organizing perception of being in charge of cause-effect, input-outcome, and action-result. In particular, efforts to optimize reward, self-enhancement, and self-promotion have proved important. Decision-making as part of an agency model for narcissistic personality functioning has been studied in social psychology in the context of approach—avoidance motivation, specifically in relationships and in financial and business decisions.
Contrary to lapses in decision making, some people Self defeating behavior narcissists and sexual dysfunction pathological narcissism or NPD can present with more consistent patterns of selfpromoting decision making, involving risk-taking, and disregard or ignorance of both their own and others' feelings and wellbeing.
On the other hand, it is also possible that dysregulated feelings of fear can impact the decisionmaking patterns of these individuals.