Ester di Giacomo
Elena Andreini
Ottavia Lorusso1,2
Massimo Clerici- 1Department of Mental Health and Addiction, Health Care Trust–IRCCS San Gerardo Monza, Monza, Italy
- 2School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
Narcissistic personality disorder is characterized by self-absorption, grandiosity, exploitation of others and lack of empathy. People with that disorder may switch from an overt form, mainly with grandiosity, to a covert presentation, with fears, hypersensitivity and dependence from others. Empathy represents a key point in detecting people affected by narcissistic personality disorder because, even if it is described as reduced, it plays a fundamental role in exploitation and manipulation. A systematic search of Literature without any language or time restriction, was performed combining thesaurus and free-search indexing terms related to Narcissistic personality disorder and empathy and produced 531 results. Fifty-two papers that analyzed possible issues in the empathic attitude of people with narcissistic personality disorder were included in this narrative review. Empathy is the capability of understating and feeling others emotions. It is not a unitary construct and can be distinguished in cognitive and affective. It might be channeled into prosocial and antisocial behaviors. A crucial trait identified in narcissistic empathy is affective dissonance that is closely related to rivalry as part of the dark tetrad (narcissism, machiavellianism, psychopathy, and sadism). Subjects affected by narcissistic personality disorder show greater impairment in affective aspects while their cognitive part of empathy appears preserved. Saving at least the cognitive aspects of empathy may contribute to therapeutic improvement of affective aspects.
Introduction
Narcissistic personality disorder is characterized by self-absorption, grandiosity, exploitation of others and lack of empathy. The tendency to elicit admiration from others is epitomic, but it is manipulative and finalized to take a personal advantage. Empathy plays a crucial but ambivalent role in people affected by narcissistic personality disorder (NPD), who often misunderstand someone else’s empathic behavior and social assistance.
The rise of narcissism over the generations, as shown by increased scores in questionnaires about that disorder in American college students in the last 25 years, seems typical of western cultures and stresses the importance of analyzing such a phenomenon.
This narrative review aimed at analyzing the interplay between NPD and different aspects of empathy with the goal of a better understanding of antisocial/prosocial behaviors in NPD. Furthermore, implications and treatment options will be discussed.
Methods
A systematic search of Literature in two main databases (PubMed and Embase), without any language or time restriction, was performed until October 2022 combining thesaurus and free-search indexing terms related to Narcissistic personality disorder and empathy. The review was performed according to PRISMA-ScR and produced 531 results (207 in PubMed and 324 in Embase). Studies that did not describe both narcissism and empathy were excluded. Experimental research would be included if it diagnoses narcissistic personality disorder or analyzes empathy through standardized tests.
One-hundred eighty-nine full texts were analyzed and fifty-two articles were included in qualitative analysis (see Figure 1).
Figure 1. Preferring reporting items for systematic reviews and meta analyses flow diagram.
Results
Table 1 provides an overview of the papers included in the qualitative analysis. Most of the manuscripts were published in the last 15 years (46 out of 52).
Table 1. Studies included in qualitative synthesis.
The tests used to diagnose narcissistic personality disorder were the Structured Clinical Interview for DSM-IV Axis II (SCID-II), SCID-5-PD for the DSM-5, and the Pathological Narcissism Inventory (PNI) questionnaire. Empathy was evaluated with the Interpersonal Reactivity Index (IRI), the Multifaceted Empathy Test (MET), or the Toronto Empathy Questionnaire (TEQ).
Papers were sorted in different categories to facilitate in-depth analysis: narcissism and empathy correlation, antisocial behavior, neurophysiologic mechanisms, therapeutic implications and prosocial behaviors.
Empathy
Empathy is both an emotional and cognitive construct influenced by the interplay between traits and environment.
Cognitive empathy is the capability to figure out someone else’s emotions and it is strictly related to the theory of mind (1). It implies the distinction between personal affective states and those of others. Reflections on personal thinking and on that of someone else is named “mindreading,” or “mentalizing,” and appears a semi-independent skill (2).
Affective empathy is correlated to acquaintance with emotions, elicited by emotional stimuli. Such a definition is incomplete, since it involves only positive aspects. Some authors explicitly argued that the observed empathic reaction should be congruent with that of the person they observe (3). On the contrary, empathic deficits in people with antisocial personality disorder entail dissonant or “contrast empathy” (4), when the subject experiences hate or even joy in a situation most people live with compassion or concern.
Kealy and Ogrodniczuk (5) proposed that the affective part is the key, while the cognitive factor is the pathway that creates such content.
Empathy also involves the ability of self-judgment and awareness of distinction between the self and other people, called “emotion regulation.” Such ability involves a governance on personal conduct and appropriateness to the social environment (6).
Several researches examined the most desirable correlates of emotion recognition capabilities, for example higher dispositional empathy (7, 8). Despite it, some authors admit that emotional competence can be directed antisocially, with manipulative connotations or drive others toward sociopathy and mischievous acts (9).
Neurophysiological aspects of empathy
Some biological issues might be associated with those difficulties experienced by people affected by narcissistic personality disorder.
The primary brain structures involved in empathy are:
• the anterior insula (AI),
• the anterior cingulate cortex (ACC),
• specific regions of the medial prefrontal cortex (MPFC).
The AI and ACC are the principal intersections of the salience network (SN) (10), which chooses and organizes the flow of information from the internal and external receptors. This process might underpinning sentient awareness of feelings (11–13).
The AI might be a sort of switch center between two different networks of cognitive processing:
• the central executive network (CEN), linked to task execution.
• the default mode network (DMN), related to self-reflective processes (14).
The process, connected with affective empathy (“affective sharing”), implies the bottom-up evaluation of feelings that a subject feels in reaction to other people with equivalent feelings.
The “perception-action” model (15) explains it with a possible activation of similar brain zones [Anterior cingulate cortex (ACC) and anterior insula (AI)] in both observers and observed when the watcher examines or picture the feelings of someone they are evaluating.
On the other hand, the cognitive process of empathy is carried out by the prefrontal regions (16) and allows the observer to behave in a context-specific way.
Finally, the orbitofrontal cortex (OFC), the MPFC, the dorsolateral prefrontal cortex (DLPFC), and the ACC are involved in emotion regulation (6, 16).
Research highlights main obstacles both in the bottom-up pathway among narcissists, but the cognitive parts of empathy seem damaged as well (3, 17, 18).
Fan et al. (19) analyzed a group of non-clinical subjects, divided in high (HN) and low narcissism (LN). They were asked to empathize with images of faces expressing emotions. Evidence demonstrated a reduced deactivation of the right AI (rAI) and an increased activation of the posterior cingulate cortex (PCC), DLPFC, and premotor areas in reaction to non-emotional faces among HN people (17).
Furthermore, Jankowiak-Siuda and Zajkowski (3) examined the neurobiological roots of emphatic issues, linked them to a dysfunctional SN, determining an alteration in switching between the DMN and the CEN with an hyperactive faster DMN. The DMN is typically elicited during “mind wandering” or self-referential processing (20).
Since the insula is fundamental in the human threat detection system, NPs’ malfunction in the rAI could create disturbed estimation of some affective stimuli from the external world which are perceived as intimidating. Such an effect may increase sensitization with obstacles in moderating the response of the threat detection system (21).
Accordingly, NPs show a high degree of vulnerability to suffering, comparable to that of functional psychopaths (18).
Empathy and narcissistic personality disorder
An interplay between narcissism and empathy was investigated from the clinical conceptualization of NPD to its launch in the DSM–III (22), deficits in empathy processing was considered a hallmark of pathological narcissism (23–26).
People affected by NPD describe themselves as superior but, at the same time, depend on and manipulate others to gain visibility and admiration (a reality called “narcissist supply”) (27).
In fact, a “look but do not touch” message is epitomic (28–30). Exploitation of other people does not imply meaningful contact with the subject affected by NPD. Therefore, the overt striving for social affirmation seems linked to a covert alienation.
Ritter et al. (17) demonstrated that people affected by NPD have issues in emotional, but not cognitive empathy, possibly because reading others’ emotions might be useful to reach personal purposes (31).
Subjects with high levels of narcissism declare lower degrees of perspective taking at the Interpersonal Reactivity Index, especially in questions about willingness to focus on empathic distress. Despite being able to perceive emotions like psychopaths (1, 32, 33), people affected by NPD may have compromised empathic functioning due to deficits in emotional empathy (e.g., neurobiological evidence) and motivation-based impairment in their cognitive empathic functioning.
Narcissism is a multifactorial construct, with several (e.g., entitlement, exploitativeness -E/E- and exhibitionism, self-sufficiency, superiority, vanity, leadership/authority) dysfunctional aspects (26).
Konrath et al. (34) explored the link between exploitation and skills of emotion recognition. They demonstrated that narcissists’ ability to read others’ emotions is driven by the trait E/E. Furthermore, exploitative people are more able at recognizing negative emotions because they look for vulnerability in others to find people to take advantage of and exploit (35).
A distinction between overt and covert narcissism is mandatory. Grandiose narcissism is characterized by entitlement, grandiosity and self-absorption with self-presentation under a favorable light by expressing superiority, aiming at dominance over others.
On the contrary, vulnerable narcissism is characterized by hypersensitivity, and dependence on others that reflects a fragile idea of self-worth which is regulated by strategies like diminishing the importance of connections to others (3).
Given-Wilson et al. (36), measured empathy, identity concerns, and interpersonal difficulties with the Interpersonal Reactivity Index–IRI. Covert narcissism seemed related to higher Personal Distress and Fantasy scores. High personal distress is linked with vulnerability and fearfulness (37). Vulnerable narcissism has been associated both with the fear of being taunted (gelotophobia) (leading to social retraction and isolation) (38), and with to the joy of making fun of others (katagelasticism) (emphasizing more antagonistic attitudes) (39, 40). On the other hand, Overt Narcissism was associated with lower personal distress, indicating affective detachment or unawareness of others’ feelings (2, 41).
The negative association between empathy and overt narcissism is based on disregarding others’ feelings, while the negative association with covert narcissism might be due to worries about themselves or more intense self-consciousness and may be overwhelmed by personal emotions, with failure in recognizing someone else’s perspectives (42).
Dysfunctional aspects
Narcissistic personality disorder features indicate they do not have insufficient empathy, but that it is not efficient and subject to motivational and situational factors.
Narcissism is among malevolent traits of the Dark Triad (43), together with psychopathy and Machiavellianism. Further to this point, Gojković et al. (43) investigated correlations between Affective and Cognitive Measure of Empathy, admiration, rivalry, and the Short Dark Triad traits (SD3) (44). Rivalry, but not psychopathy, was the strongest trait of the dark core. Antagonism, embodied in rivalry, is the key part of callousness (45). Accordingly, rivalry predicts a lack of acceptable emotional response or recognition of someone else’s feelings, but also contradictory affects, a phenomenon called “affective dissonance.”
Intolerance toward emotions can play a role, since the subject might detect feelings in others, but that perception may arouse overwhelming power deprivation, shame or loss of internal control, thus stimulating aggressive responses or withdrawal (46). Such intolerance can coexist with reactivity to negative events and anticipation of humiliation (47) can coexist with emotional intolerance and issues in processing emotions, especially fear and shame, with reactive strategies of avoidance as well as defensive revengeful anger to regain control.
Furthermore, significant fluctuations in NPD empathic skills might be affected by self-regulation, increased when they feel confident and decreased when they are exposed or threatened (43).
Antisocial behavior
It is crucial to understand the impact of narcissism on society and explore how to reduce antisocial behavior and improve prosocial ones.
Amiri and Behnezhad (48) highlighted that violent male offenders with “antisocial and narcissistic” traits have significant criminal careers. Vaughn et al. (49) showed that narcissistic items of the psychopathic personality inventory correlated with incarcerations and assaults in the previous 2 years (50). Johnson et al. (51) found that NPD symptoms in early adolescence prognosticate violent criminal behavior in mid-adolescence and early adulthood (52).
Narcissistic traits are escalating in western society with a 30% rise in the past 30 years (53) leading to increased criminal behavior with relevant public concern. People with a high level of narcissism respond aggressively toward a challenging source (54), presumably to regain self-esteem and dominance over others.
Beyond their motivation to aggressiveness or exploitation, it is questionable that a lack of empathy could be responsible for their impulsivity or devious plans, while disregard for others may support aggression as a response to perceived threats.
Barry et al. (54) demonstrated an inverse relation between empathy and aggression in narcissistic adolescents. Having some concern for others may result in a search for alternative strategies (e.g., manipulate others, self-aggrandizement) to reach social goals (55).
Grandiose narcissists may show overt empathic detachment, such as clear refusal, harsh criticism, and disapproval of others.
Therefore, when in a grandiose state, those empathic frailties may stimulate self-interests or competition.
Leaders with NPD can show both empathic issues and psychopathic, power motivated functioning, leading to illegal actions and active exploitations for personal gains (56).
Furthermore, Hepper et al. examined the effects of clinical and subclinical traits NPD on empathy in male prisoners compared to those with no criminal history. Being an offender is best predicted by entitlement, which is maladaptive in terms of antisocial behavior than NPD symptomatology.
Although lack of empathy gives a narcissist the “green light” to commit a criminal act, the initial feeling of deserving the best may also be crucial for narcissistic crimes (57).
Prosocial behavior
Antisocial and prosocial behaviors are not antithetic. Prosociality might hide several reasons, even egoistic, such as receiving praise or attention, or having something in return (58). According to the Extended Agency Model (59) higher levels of narcissism are associated with more self-enhancement of qualities like intelligence and extraversion, but not agreeableness or morality (32, 60). This model affirms that narcissism intensifies the reward experienced from situations like having a social high status and power and, as a consequence, it leads to being more focused on success, power, and attention, and less on caring for others.
The prosociality of high narcissistic people is goal-directed to gain visibility and being ascribed as positive and talented. For example, they help people when others are watching but not anonymously. Moreover, they are likely to engage in “slacktivism” by posting online, despite donating money (61).
Accordingly, they can be labeled as strategic helpers, since they help others if they could help themselves in return (e.g., by receiving attention that implements narcissistic esteem).
Therapeutic implication
Some theoretical models stress the core role of motivation as crucial in NPDs’ behavior and empathy, giving some room for change through psychotherapy.
Experts have different opinions about the best treatment approach, but patients affected by NPD are often considered resistant or even untreatable (62, 63).
A better analysis of the interplay we explored in this review aimed at stimulating awareness and more specific treatments.
Evidence suggested that the capacity for self-reflection and ability to think about someone else’s, sometimes called theory of mind or mind reading, are not the same thing but have reciprocal influence. Despite this, difficulties in one capacity predict difficulties in another (64).
Clinicians noted that patients with NPD have difficulty in facing their own emotions and in recognizing possible interpersonal reasons for their feelings (65). Moreover, self-awareness should be a priority to reach the awareness of others. Since narcissists see others as either alien or hostile, any attempt of mindreading before self-reflection probably is experienced as a request to “take the enemy’s part,” resulting in a stressful experience.
Instead, encourage self-reflectivity as first step may persuade patients to be more aware of their real attitudes, opposing to characteristics they simulate to achieve social acceptance (66).
Dialectical Behavior Therapy is based on the agreement that emotions might be frightful and at times, unbearable. This skills-based approach is recognized to support NPD people in determining their own needs and values and answer to responses from others appropriately (67). Furthermore, during therapeutic settings interpretations should be verbalized as questions or hypotheses, to facilitate the patient’s introspective interest and reduce negative responses.
Furthermore, since narcissists’ low empathy is induced by motivation, and, on that basis, simple perspective-taking instructions may be worth it in treatment.
When instructed to take the perspective of a suffering target person, the lack of empathy is lowered.
Consequently, addressing empathy in education, training, or public campaigns might be an efficient way to get to the heart of narcissists’ inadequacy (57).
Turning to talking about new perspective about drug therapy, based on a much less solid body of knowledge, van Mulukom et al. (68) showed that classical serotonergic psychedelic (CSP) drugs, thanks to induction awe and ego dissolution, may reduce of maladaptive NPD traits, such as a strong sense of entitlement and lack of empathy. The experience of ego-dissolution and lowered focus on the self, as induced by psychedelic drugs appear antagonistic to the self-focus and self-importance that is characteristic of high trait narcissism (68).
Discussion
People affected by NPD show specific issues in empathy, but those difficulties are limited to its affective part. In fact, the cognitive portion seems preserved and essential for manipulative skill and exploitation of others.
Subjects with NPD may experience those problems with affective empathy because they feel others’ emotions as threatening and dangerous and react with detachment to preserve their own personal integrity. In addition to exploitation, a lack of empathic affectivity appears associated with proneness to criminal behaviors, particularly when NPD coexists with antisocial traits, contributing to psychopathy.
Furthermore, rivalry seems the key feature among the Dark Triad traits that supports callousness (44, 45) to its extreme pole embodied in “affective dissonance,” with contradictory affects in response to someone else’s feelings.
That alarming evidence, in terms of social implications and patient’s wellbeing, is often accompanied by poor therapeutic approaches. NPD patients are often labeled as untreatable, but self-reflection as a first and fundamental approach may represent a key step in facilitating the comprehension of someone else’s feeling and a crucial gateway to treatment.
Limitations
Research on narcissistic personality disorder is limited. Patients affected by narcissistic personality disorder are often considered among the most difficult to be treated (62, 63). The fragility of their ego together with the tendency to impulsivity often obstruct the possibility of access to dynamic psychotherapy, which is considered the best treatment option. The crucial point in the treatment of NPD patients is their will to be treated (66), which is fundamental in psychotherapy. Such patients often consider treatments as a personal failure and refuse it.
Due to their label as untreatable, studies focused on the efficacy of psychotherapy in those patients are few and, consequently, those that analyze empathy and its correlates are even fewer.
Furthermore, most of the research is led on western populations, probably due to the rise of this illness in western cultures. This might represent an additional limitation because results cannot be generalized.
Conclusion
Narcissistic traits are widespread in the contemporary Western population. Empathy plays a crucial role in both intrapersonal and interpersonal aspects of that personality disorder and influences both prosocial and antisocial behaviors.
Narcissism, although related to grandiose self and exploitativeness, is deeply associated with great personal suffering, vulnerability and correlates with important social consequences. Evidence of an ambivalent relationship between NPD and empathy, and the chance to work on therapy about this aspect, stress the importance of developing strategies to help patients with NPD to achieve a functional affective empathy.
Limits are many and consistent, but this manuscript aims at highlighting the evidence to date and stimulates further research due to the severity of this disorder and its spread in the general population, especially in the youngest part (adolescents and young adults).
Author contributions
EdG planned the project, supervised the data, and literature analysis. OL and EA searched the database and analyzed the literature and data. EdG, OL, and EA wrote the manuscript. MC supervised the project. All authors approved the final version of the manuscript.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
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Keywords: empathy, crime, narcissistic personality disorder, psychotherapy, rivalry, mentalization, mindreading
Citation: di Giacomo E, Andreini E, Lorusso O and Clerici M (2023) The dark side of empathy in narcissistic personality disorder. Front. Psychiatry 14:1074558. doi: 10.3389/fpsyt.2023.1074558
Received: 19 October 2022; Accepted: 28 February 2023;
Published: 30 March 2023.
Edited by:
Massimiliano Beghi, Azienda Unità Sanitaria Locale (AUSL) della Romagna, ItalyReviewed by:
Giulio Castelpietra, Direzione Centrale Salute, ItalyMarco Menchetti, University of Bologna, Italy
Copyright © 2023 di Giacomo, Andreini, Lorusso and Clerici. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Ester di Giacomo, ZXN0ZXIuZGlnaWFjb21vQHVuaW1pYi5pdA==