Kirsten Clark

Most practising psychologists have encountered patients with Narcissistic Personality Disorder. For the most part, they are fairly easy to diagnose based on the DMS 5 criteria – we typically look for signs of a lack of concern for others’ feelings, grandiosity, a sense of entitlement and self-indulgence. But just as there are nuances in the presentation of borderline patients, there may also be more than one type of narcissist.

The concept of refining the diagnosis of patients with personality disorders using sub-typing or trait specific taxonomies was first mooted in the early 1990’s. The updated versions of psychometrics such as the MCMI and the MMPI had given practitioners more sophisticated tools to fine tune their diagnosis to include profile types.

Craig (1993) created a series of profiles based on “personality styles” (pg. 73) as identified in the second edition of the MCMI. Using a concept of cluster profiling rather than using single scale elevations, Craig identified various profile types. For example, two patients may have similar elevations on the Negativistic Scale on the MCMI (Scale 8A). However, one patient has a second elevation on the Dependent Scale (Scale 3) and the other peaked on the Antisocial Scale (Scale 6A). The clinical presentation, the personality dynamics, defense mechanisms and treatment approach will be different for each patient, based on how they can be categorised using style clusters rather than individual scale elevations.

In 1991, Paul Wink from the University of California Berkeley, published a paper entitled “The Faces of Narcissism.” Wink used a psychodynamic conceptualisation of slitting to argue that as Narcissistic Personality Disorder was inherently based in self-esteem issues, it could therefore manifest itself in different forms. The first “face” that Wink described in his paper was the ‘typical’ narcissistic presentation – the “overt [expression of] grandiosity [which] leads to a direct expression of exhibitionism, self-importance and [a] preoccupation with receiving attention and admiration from others” (pg. 591). Underlying the grandiose posturing is contradictory and crippling low self-esteem and inferiority. Wink termed the presentation of the arrogant, self-assured and superior narcissist as being overt or Grandiose-Exhibitionist. The grandiose-exhibitionist type of narcissist is characterised by their consistent and public show of aggressive disdain for others.

He then described a second “face” of narcissism, known as covert or Vulnerable-Sensitive. This type of narcissism carries the mark of the classic underlying neurosis of low self-esteem closer to the surface than the overt narcissist. This type of narcissist may be unaware of their delusions of grandeur and will initially present as sensitive and insecure. However, the vulnerable exterior eventually gives way to the “grandiose fantasies” (pg. 591), sense of entitlement and willingness to exploit others. Wink (1991) described covert narcissists as “defensive, anxious, emotional and moody, bitter and discontented” (pg. 596). He further noted that while the vulnerable-sensitive narcissist will appear socially reticent, closer inspection of their intimate relationships will reveal a tendency towards self-indulgence and an overwhelming drive to have things done as they please.

Wink (1993) argued that these two faces of narcissism share certain characteristics, namely conceitedness, entitlement and a disregard for the feelings and needs of others. However, he further argued that the nuances that play out in the type of narcissism will have profound impact of the management of the patient. It may therefore be more appropriate and practical to view Narcissistic Personality Disorder as existing on a continuum moving from Grandiose-Exhibitionist (overt) to Vulnerable-Sensitive (covert).

The concept of an overarching taxonomy that requires further and increasingly more sophisticated subtyping based on personality styles is inherently complex and nuanced. The subtypes of overt and covert narcissism are multifaceted and, as with so many of the conditions we work with as clinicians, delineating ‘the face’ that we are dealing with can be challenging.

One way to prepare ourselves for the possibility that a patient may be a covert narcissist is to identify and examine any “hypersensitive fixation around the presumed incessant attention from others” (Esposito, 2015). By asking ourselves if the patient has come for therapy because of a desire to change their own behaviour or if they are there as a means of controlling and changing others, we may be able to better identify these apparently shy and sensitive personalities who are displaying their sense of entitlement in a different way (Peterson, 2017).

References:

Craig, R. J. (1993) Psychological assessment with the Millon Clinical Multiaxial Inventory (II): An interpretive guide. Psychological Assessment Resources.

Esposito, L. (2015). Shy, sensitive, introverted… and narcissistic? Downloaded from https://www.psychologytoday.com/blog/anxiety-zen/201508/shy-sensitive-introverted-and-narcissistic on 7th February 2018.

Peterson, N. (2017). Telling apart grandiose and vulnerable narcissism. Downloaded from https://blog.allpsych.com/telling-apart-grandiose-and-vulnerable-narcissism/ on the 7th February 2017.

Wink, P. (1991). Two Faces of Narcissism. Journal of Personality and Social Psychology, 61(4), 590-597.


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