Daniel Knoepflmacher, MD (Host): Welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychology, research, and other important topics on the mind.

In 1979, the historian and cultural critic, Christopher Lasch, wrote a book entitled The Culture of Narcissism: American Life In an Age of Diminishing Expectations. The book had a tremendous impact in its day, and his views created political controversy, sparking discussions about narcissism in our culture that have only continued to grow in the years since.

In describing narcissism in a later book, Lasch wrote that it's a "difficult idea that looks easy, a good recipe for confusion." We live in a time when the hashtag narcissism has over 1.6 billion views on TikTok. And the topic of narcissistic personality disorder is regularly discussed in popular media. Great public interest in a compelling but complex psychological condition is a recipe for great misunderstanding. My goal today is to help those of you who are listening gain a more nuanced understanding of narcissistic personality disorder, its characteristics, variations, and the distinction between common narcissistic traits and pathological narcissism. We'll explore diagnosis, treatment, and narcissism in American culture.

It's a lot to cover, so I'm fortunate to have a renowned expert on this topic. Joining me today, Dr. Diana Diamond. Dr. Diamond is a senior fellow at the Personality Disorders Institute here at Weill Cornell. And in addition to being on our faculty, she's also an Emerita Professor in the Doctoral Program in Clinical Psychology at the City University of New York. She's internationally known for her work on personality disorders, having written extensively on the topic, including a book she co-wrote in 2022 on Treating Pathological Narcissism with Transference-Focused Psychotherapy. Diana, thank you so much for joining me today.

Diana Diamond, PhD: Thank you, Daniel. And thank you so much for inviting me. I totally support the idea of doing this podcast. You mentioned my book and never expected the book to be as successful as it has been. It's now being translated or in the process of being translated into eight languages, and I'll talk a little bit more about that in a minute.

But along with the book, I made some podcasts. And actually many, many more people listen to the podcast than will ever read the book. And in fact, I get almost on a weekly basis inquiries from people from almost all over the world, including Asia, Latin America, Europe, and all parts of this country, asking me about treatment for either themselves, their family members, spouses, parents, children, et cetera, who they have self-diagnosed as having pathological narcissism. So, I'm a full believer that podcasts reach a great number of people that ordinarily might not be aware of our work. So, thank you. Thank you for inviting me. And also, thank you for doing this series. I've listened to some of the other podcasts, and they're really wonderful.

Daniel Knoepflamacher, MD: Yeah, it's funny, because you and I have been talking about doing this episode together for many months now. And I'm thrilled that we're finally doing it. I want to begin by asking if you could share your own story. What led you to become a psychologist specializing in personality disorders?

Diana Diamond, PhD: Well, of course, that's a very long story, but I'm going to try to make it short, because there's personal and professional reasons. I was actually studying literature, Comparative Literature and Critical Social Theory. And I was reading both the Frankfurt School, people like Adorno and Horkheimer, who had been writing about the rise of fascism in Germany and had been talking about shifts, changes in the personality structure of individuals. They talked about it just in brief, going from internalization, strong internalizations of parental figures and authority figures to externalization of taking their own ego and ego ideal and projecting it onto authoritarian leaders and emptying out the self.

So, they wrote about how narcissism replaced internalization at a certain point in history. And then, I started reading Christopher Lasch's book on the Culture of Narcissism in the United States. And I just became fascinated with the idea of the continuity between the normal and the pathological that, just as we had hysteria in Freud's day was an exaggeration of typical personality traits. What Lasch saw in the 1970s was a continuity between social personality traits of narcissism, the shallow self-absorption, the captivation with celebrity and consumption, the use of social media for endless self-aggrandizement and transient superficial encounters with others.

And of course, that's become even more exaggerated now. These were narcissistic traits that he mentioned in the general population, and I became captivated with the idea of how do you distinguish between those and then pathological narcissism as a particular form of personality pathology. After that, I switched to Psychology, switched from Comparative Literature to Psychology. I did a postdoc at Yale, working with very disturbed patients at the Yale Psychiatric Institute, young adults either with personality disorders or depression. And then, I came to my first job that was at Cornell Westchester as a psychologist on one of the borderline personality disorders units.

And then, I began to work with the Personality Disorders Institute under the leadership of Otto Kernberg and John Clarkin, who became my mentors. And we had ongoing supervision groups right from the beginning of my work at Cornell that were extremely valuable in my clinical training. During the '70s when I was reading Christopher Lasch, I was also reading cohort and Kernberg. And so, here was a fascinating parallel between the social theorists who were writing about narcissism in the general population and then these clinicians who were really defining the contours of narcissistic personality disorder. It's hard to remember now that they were really the pioneers. And of course, they had somewhat different views, but they all converged on this was a particular type of personality that was organized around what they both called a grandiose self.

So, In our supervision groups at the Personality Disorders Institute, we began to present our more difficult cases. And we noticed that many of these cases, even if they had borderline structure, borderline personality organization, also had narcissistic pathology. So, combined borderline and narcissistic patients that we found were causing us the most difficulty as clinicians. They had precipitous dropout, long unproductive treatments or treatment stalemate. And this is probably the most important thing, they engendered extreme feelings of countertransference, feelings of anger, hopelessness, often because of their relentless evaluation of the therapist, their emotional detachment and refusal really to engage in therapy. But using therapy as a sounding board, using the therapist as a sounding board, feelings of boredom that the therapist experienced in the face of this. Often, the narcissistic patient's unwillingness to even acknowledge or work with the interventions or build on interventions made the therapy somewhat ungratifying.

And then, there was the flip side, which was the unnerving idealization of the therapist. And that we found actually did lead in some cases to crossing of boundaries. And there's some interesting research on this, which shows that crossing of boundaries is more typical with narcissistic patients than it is with borderline patients, interestingly enough. And this was at a time when a lot of our colleagues in the personality disorders center really didn't want to treat narcissistic patients. They said, "No, they're much too difficult. We'd rather treat borderlines." And this goes on to this day when we present at conferences and so on. People say, "I don't know how you can treat these patients." But at the same time, some of us were quite captivated by them. Some of them tend to be quite accomplished, interesting, creative. So, we set about both clinically and also in terms of doing some research to try to understand these patients better. And that led to us writing this book, treating pathological narcissism with transference-focused psychotherapy.

The goal really was to create a clinical guide that would help clinicians be able to deal with the challenges of treating this particularly difficult group of patients. And as I said, the book has now been translated into eight languages. Much to my surprise, some of those translations, for example, Russian, Hungarian, Polish, Chinese, and Farsi are taking place in countries that have authoritarian leaders. And this is particularly gratifying, because in the book there's a chapter on malignant narcissism in leaders in groups. So, I just want to mention, that a unique aspect of our group is we've concerned ourselves-- and this is under the leadership particularly of Dr. Kernberg-- with the relationship between collective and individual narcissism, and also with the ramifications of pathological narcissism in political and organizational life. So, we focused on the aspects of the rise of leaders with malignant narcissism. These leaders tend to foster collective narcissism in their citizenry. They promise a restoration of tribal forms of supremacy. And usually, this is at the expense of demonized outgroups. And it substitutes for promoting a truthful and complex view of reality and humanistic ideals of individual autonomy, social responsibility, and equality.

Daniel Knoepflamacher, MD: Thank you, Diana. I mean, it's impressive hearing about all the work that you've done with all of your colleagues at the Personality Disorders Institute. And as we delve into this topic, it's complicated. As I mentioned, there was a quote about the complexity of this condition. And I was wondering if you can help us clarify kind of the spectrum. So, the differences between healthy self-affirmation, let's say, more widely observed narcissistic traits that I think all of us exhibit at certain times. And then, the level of pathological narcissism that is defining of narcissistic personality disorder.

Diana Diamond, PhD: And this is a really important topic because narcissism has come to have a very negative connotation. And I think we really have to differentiate between healthy, what I'd call adaptive narcissism and pathological narcissism. So, let's start with healthy narcissism.

Healthy narcissism is just pleasurable and functional self-regard and self-affirmation. But that has to go along with realistic self-appraisal. So when we give the diagnosis of narcissistic personality disorder to people, we try to describe certain things. And one of the things we describe is that often those who have NPD have a very exaggerated sense of their own potential and their self-regard and their self-affirmation and their aspirations are not in line with their realistic self-appraisal. That is not the case in those with adaptive narcissism. They can realize their aspirations. They can maintain their self-regard regardless of the vicissitudes of successes or failures. They can satisfy their own needs and desires in harmony with their values and the social context. So, normal narcissism involves also an investment in a realistic representation of the self, but also in a aspect of the self that contains valued representations of others. So, we think about the internal world.

I follow what's called object relations theory, which was developed by Otto Kernberg and his colleagues and others. But he's really the primary North American object relations theorist. And in this view, the internal world is made up of images of the self, images of others and their interaction. And in healthy narcissism, there's an in-depth investment with images of the self and interaction with others that are healthy and nourishing and valued.

Now, pathological narcissism, you have something quite different. We don't think that there's just a kind of continuity between normal narcissism and pathological narcissism. Pathological narcissism is somewhat of a different animal. There's investment not in a realistic self, but what we call a pathological grandiose self. And this exists at different levels of severity, which we'll talk about in a minute. But there's inappropriate emphasis on self-enhancement, self-serving biases and beliefs that leads to dysregulation, affective dysregulation, dysregulation in social cognition, because they're not in concert with what one is experiencing. One can have entitled expectations. And when those aren't met, one can go into a state of affective dysregulation. So, normal narcissism involves adaptive and self-esteem regulation and autonomy. Pathological narcissism is maladaptive strategies and excessive dependence on external validation and dysregulated responses to unmet needs.

Daniel Knoepflamacher, MD: So to clarify, I mean, let's talk about the healthy self-regard. Someone who has healthy self-regard might have some big ambitions, but they're also able, at the same time, to hold their fallibility, their ways in which they maybe made mistakes or are weaker in certain ways at the same time that they can regard their positive qualities and have a self-appreciation in that matter. There's a balance between the good and the bad. Is that accurate?

Diana Diamond, PhD: Yes, that's accurate. They can integrate positive and negative aspects of self. But more importantly, or as importantly, they can maintain a consistent positive self-regard regardless of the vicissitudes they encounter in life. At the same time, that self-regard is in line with realistic appraisals.

So, someone with pathological narcissism will maintain positive self-regard, but it won't necessarily be in line with what they're experiencing. Or many people with pathological narcissism arrange their lives so that they only get affirmation and approval and their relationships are based on that. And they won't come to treatment or experience distress until that breaks down.

Daniel Knoepflamacher, MD: I want to turn to the pathological side, because even within the presentation of narcissistic personality disorder, there can be a lot of variability. And you alluded to grandiosity. I think that's our popular conception of these feelings of superiority, entitlement and need for adulation, lack of empathy for others. As clinicians, we often encounter people with this diagnosis and we see the vulnerable aspects of pathological narcissism, and that's marked by something you alluded to, I think, a fragile self-esteem, insecurity, extreme sensitivity to criticism.

And this distinction tracks with something that was taught way back when I was a resident about the concept of the thick-skinned narcissist versus the thin-skinned narcissist. And of course, those are rules of thumb that help us kind of identify things, but they don't really encompass the fact that, I imagine, there's both grandiosity and vulnerability in all narcissistic pathology. So, I'm wondering if you can really help us sort through these different permutations.

Diana Diamond, PhD: Well, thick-skinned and thin-skinned narcissism really do map onto vulnerable and grandiose narcissism. With the thick-skinned being grandiose, obviously the thin-skinned being vulnerable. So, I'm going to use those terms.

I think that we have to understand that pathological narcissism, it really refers to a very broad range of conditions, not specifically narcissistic personality disorder. So in our book and also just in our work in the Personality Disorders Institute, we really have a developmental dimensional model of pathological narcissism. We think it exists at different levels of severity. It encompasses diverse presentations. And we'll get into that in a minute.

So, grandiosity and vulnerability can look quite different depending on the person's level of organization. But let's just start with, in the general population, as we were talking about before when we were talking about Lasch's book, there are narcissistic traits and these include self-entitlement, exploitativeness, self-aggrandizement, lack of empathy, self-centeredness, and vulnerability, and some grandiosity. I want to say that we have to be careful about grandiosity because grandiosity is not always pathological. You have to evaluate it in the context in which it's occurring.

So, for example, grandiosity is very different from somebody who made a significant scientific discovery and aspires to win the Nobel Prize, versus somebody who's grant was turned down who falls into a depression, hides out in the parents' basement, but still believes that they might actually win the Nobel Prize. So, it serves different functions, you see, depending on what the context is. So, we do see more normative grandiosity.

Now, those with narcissistic personality disorder, as we've talked about, tend to have characteristics of both grandiosity and vulnerability. And interestingly enough, those who have pathological narcissism almost always have grandiose and vulnerable characteristics that kind of coexist in dynamic relation to each other. Although I should tell you that grandiosity is the strongest evidence-based treatment for pathological narcissism, but defective self and affect regulation that lead to vulnerable self states is also part of the syndrome.

Daniel Knoepflamacher, MD: What about the levels of severity in narcissistic personality disorder? How do these emerge in your work as a therapist?

Diana Diamond, PhD: Okay. So, this is a really, really important concept. We think about pathological narcissism existing at different levels of severity. So, as I said, we think about it as a dimensional disorder. Higher functioning narcissists often show social competence. They might be quite accomplished. They often have what we call cognitive empathy. They can understand the feelings and needs of others at an intellectual level, but they usually lack emotional empathy. They may seem more superficially healthy. They usually have a grandiose self that's more stable. Maybe I should stop for a second and just define what we mean by the pathological grandiose self.

That is a self-formation where ideal images of the self and the other are kind of hoovered into the self, and it creates an inflated sense of self. And everything negative about the self, everything weak, inadequate vulnerable tends to be projected onto others. Then, those others are devalued, and that's creates the kind of relationships that you often see including it in the transference, in the relationship to the therapist of the superior self and the devalued other. But that grandiose self with this relentless projection of everything negative lends some superficial stability to those with narcissistic pathology, particularly in those who are higher functioning. And in those who are higher functioning, those ideal images of self and other, although they inflate the self, there's also some realistic sense of the self and the self's potential. And that's why they tend to function much better. Also, they have somewhat superficial and stable relationships.

If we move down the developmental ladder to the borderline level of functioning, and these are individuals who have much more difficulty with identity, those who are higher functioning have a more stable sense of identity. But at the borderline level, you have individuals who have identity diffusion, confusion about who they are, changing their goals, friendship patterns, aspirations from day to day. And they have a much more fluctuating grandiose self fluctuating between grandiosity and vulnerability. and there's been actually quite a bit of research on this, which shows that those who have vulnerable narcissism as their primary manifestation are those who really are organized at the borderline level. And they also have a much more tendency toward affect dysregulation. In the face of ego threats, they can become quite dysregulated. And those ego threats can spark aggression. They have sometimes difficulties managing that aggression and also their envy. We know that narcissistic patients tend to be prone toward having difficulties with negative affects, particularly anger and envy, and maybe envy most of all because they tend to be preoccupied with envy. So, those at a borderline level are functioning in a much more chaotic way, both in work and relationships.

And then, at the most disturbed level, we have malignant narcissism. And those with malignant narcissism have a grandiose self that's infiltrated with aggression. They tend to be quite paranoid, create paranoid constructions of relationships with others. And they also tend to have much more compromised moral functioning or what we call antisocial features. And these are individuals who when there's a collapse of their grandiosity or when there's attacks on their grandiosity, or it's challenged in any way, they actually can lose their reality testing, when external events challenge their self-image. So, this is the most severe form of the pathology. Although again, even those with malignant narcissism sometimes can function well if they are in a situation where they arrange to get infusions of approval and admiration that you don't threaten their grandiose view of the self.

Daniel Knoepflamacher, MD: Like maybe they have extreme talent in a certain way or power politically or something like that perhaps?

Diana Diamond, PhD: Well, these are sometimes, interestingly enough, people who aspire to leadership positions and often attain them. So, there's a lot of-- in the popular press now-- about pathological narcissism and particularly malignant narcissism in leaders in groups.

Daniel Knoepflmacher, MD (Host): Well, you brought up something, you used the term ego threat. You talked about the failures of these grandiose aspirations. There's a term that's often used, narcissistic injury. Could you speak about that for a minute?

Diana Diamond, PhD: Yes. If there's a pathological grandiose self in which all ideal views of the self and others inflate the sense of self, right? And yet, this is not a realistic view of self. But everything that's weak or seen as inadequate or whatever tends to be projected onto others. That leaves the person prone to narcissistic injuries. Because although they can arrange their lives and their relationships to affirm those, that view of self, the vicissitudes of life often challenge that. So, we see this particularly at two stages of life.

First of all, aging. Aging poses a tremendous challenge to pathological narcissism. In the later part of the life cycle, as the sort of gratifications of achievements and so on begin to become redundant or not as important, not as ego-gratifying, the individual can find themselves, or over time ways in which narcissistic individuals treat others as extensions of themselves, as sounding boards or mirrors for the self, that wears thin. And so, sometimes partners, coworkers, children confront the narcissistic individual, and they have to come face to face with the damage that they've done to their relationships. And that can be quite a severe narcissistic injury.

So, we often have individuals in late midlife or even old age coming to treatment, interestingly enough, at that point in their life when they have to face the limitations on their grandiosity, the narcissistic injuries of aging, the loss of physical prowess. They often feel a sense of futility and emptiness at that point in their life because they haven't invested deeply in relationships. And so, these narcissistic injuries can compile at that point in the lifecycle.

The other place where you see this is in the transition into the real world, so to speak. So, we have a lot of what we call failure to launch individuals coming through the Personality Disorders Institute. So, these are individuals who they might have some deficits, learning disabilities or difficulties, emotional, or cognitive difficulties. But they've gotten through high school, college with armies of tutors, often hovering helicopter parenting, parents who help them write papers, help them do their homework, et cetera, et cetera. But when they make that transition from college to the real world, so to speak, and they have to get a job, we see quite a few kids in that age group who are just collapsing, and they're not able to get a job that they feel is commensurate with their abilities. They've been given by parents an inflated sense of their own potential, which they've internalized. And that's led to a certain modicum of pathological narcissism. And so, they feel shortchanged, they feel very angry. They often retreat, live in the parents' basement, or they have a series of jobs that they can't hold because they're not willing to do the kinds of work that one does at entry level jobs. They often turn to substances to prop them up. So, we see narcissistic injuries, particularly in young adulthood and also later in life.

Daniel Knoepflamacher, MD: And those are two times, as you said, when people come to treatment. I'm curious about the prevalence of narcissistic personality disorder, because not everyone, I imagine who might fulfill all the criteria, not all of them are coming in to be treated. So, what is the prevalence in the general population?

Diana Diamond, PhD: That is kind of in debate, let me put it that way. There are large scale surveys and there was one done by somebody named Stinson who surveyed many thousands of individuals normative individuals using the criteria, the DSM criteria for pathological narcissism, which does tend to privilege grandiosity. And we'll talk about this in a minute, there's different ways to diagnose narcissistic pathology. But in that study, it was found that something like 6.2% of individuals in the United States do show characteristics of pathological narcissism. Now, there was differences between men and women, I think it was four some percent for women, and seven some percent, 7.3, something like that for men. Interestingly enough for younger people between the ages of, I think it was 18 to 20, something like that, the proportion of the population that had pathological narcissism was 9%. So, you see narcissistic pathology, as I said, sometimes more prevalent in younger people in our society right now.

Now with that said, because the criteria for evaluating pathological narcissism was really based on the DSM grandiose criteria, this is probably an underestimate, because we now think about pathological narcissism as on a continuum, as I said. So, these are probably underestimation of the level of pathological narcissism. Interestingly enough, in a couple of surveys of clinicians, one done by somebody, who surveyed clinicians in the United States, Canada, and Australia, they actually found that between 20 and 76%. Of clinicians in different countries reported treating patients with pathological narcissism.

So if you ask clinicians, and these were clinicians of all different theoretical persuasions, if you ask clinicians, they will report much higher levels of, of patients with pathological narcissism in their practices. And I have to say that, we presented our, work, on TFP transference focused psychotherapy for pathological narcissism in many different places and really in United States and internationally.

And, it's always astonishing to us how many people come to hear us and how many people say to us, clinicians say, these are our patients.

Daniel Knoepflmacher, MD (Host): Yeah. Well, that's an interesting point because, I mean, I think there is a, sampling that clinicians are going to see that shows more severity that people are, are seeking treatment. And then, you know, as you're saying, maybe the number of six something percent is maybe too low. it's, I guess, a hard thing to determine.

I, want to turn though, to an important piece of this because it, it's not an insignificant. Prevalence, of narcissistic personality disorder in the population. There is an association with a risk of suicide, and I wanted to see if you could speak to suicide in this population.

Diana Diamond, PhD: Yeah, this is a very, very under theorized and un under-discussed. Aspect of pathological narcissism. I mean, we do see. Suicide is different in those with pathological narcissism versus with those with, normative narcissism. those with pathological narcissism. they have a different form of suicide.

It's often suicide that comes out of the blue. It's also more lethal. so there was a study done at, the Clips study at Columbia, which actually followed, I think it was patients from the Psychiatric Institute. And it followed them into the outpatient phase, I think, for quite a few years. And what they found is in the first five years, those who were borderline were, as a primary diagnosis, were much more likely to make, parasuicidal gestures, but not to kill themselves.

Those who had NPD as a primary diagnosis were more likely to make lethal suicide attempts. So, you read all the time about these suicides that come out of the blue. I. With very high functioning individuals, and often these are individuals who have not told their therapist that they were suicidal.

suicide for those with pathological narcissism can be a kind of get out of jail free card. they feel like if all else fails, they can always kill themselves. So interestingly enough, it can, the idea of killing oneself and having that as a secret can also be a stabilizing factor and a protective factor against suicide.

But on the other hand, should they be subject to, as you pointed out before, severe narcissistic injuries, or should their narcissistic defensives fail for one reason or another, they are prone to sudden and lethal suicide. so this is something that, is very important in terms of treatment because anybody who's treating individuals with narcissistic pathology always.

Has to be aware that this is a possibility. Assess for it. And that's why in transference focused psychotherapy, we work with treatment contracts and we assess very carefully at the beginning of treatment for any self-destructive behavior. often. W the suicidal behaviors, they're not shared with the therapist, as I said, but over time, you know, you can become aware of people driving under the influence or doing things that, they won't admit are suicidal, but that the therapists can see could be self-destructive or suicidal.

in addition to that, should say that those with narcissistic pathology also engage in a lot of self-injury, skin picking, hair pulling, that kind of thing. and again, we don't usually associate these, kinds of behaviors with narcissistic patients, but they are very common.

Daniel Knoepflmacher, MD (Host): So, I want to talk a bit about the factors that lead to narcissistic personality disorder. both, I guess in the genetics and biology, what we know about that.

And then of course the early life experiences.

Diana Diamond, PhD: Yeah, so we, call this our contemporary object relations model. Of pathological narcissism. So I already talked about the intrapsychic structural factors, right? But we believe that those intrapsychic structural factors, have a number of vectors combined to create those. A pathological grandiose self, which again, is a condensation of ideal views of self and other, and the real self.

it's a kind of split structure. but in addition to that, there's temperamental factors. Okay? So temperamental factors are extremely important. The child may be predisposed, and there's been some research now longitudinal research on individuals who go on to develop, narcissistic traits in adolescents in early adulthood.

And, children who are very sensitive to approach and rewards and who seek praise and attention, unduly seek praise and attention. Or conversely, children who avoid closeness with others and they cope with adversity through extreme self-reliance. there's someone named Simington who's part of the British Middle School of Psychoanalyst in England, and he made the observation, which I think is really important if you work with narcissistic patients, that he's never seen a case of a narcissistic individual who, when they go into their history, didn't themselves turn away from the caregivers at some point in their development.

and if you look at some of the mother infant. Research it's very interesting because you can see that what happens with the mother and the mother's caregiving is also dependent on the extent to which the child is receptive to it. So these may be individuals who have premature ego development and strength.

And I think that accounts for some of the strength of those with narcissistic pathology. then there's genetic factors. the twin studies show 25 to 79% heritability rate and the higher over 70% heritability rate in clinical groups. and then probably much more important than that is familial factors exploit on the part of the parents over-involved parental attitudes.

Kernberg growth many, many years ago. As parents who treat the child as an extension of themselves and their own narcissism, they often the child will have unusual Positive characteristics, unusual physical, intellectual, creative characteristics. and they're, they feed the parents' narcissism.

conversely, parents can also be very cold and controlling. So there's two different styles of parenting that feed into pathological narcissism. And then I think another very, very important thing is that abuse and neglect have been associated with pathological narcissism and particularly emotional.

there's specific linkages between emotional abuse and NPD, and then the development of insecure and disorganized attachment coming out of this type of parenting. And we're going to talk about that in a minute. also deficits in social cognition. these are individuals who sometimes, have difficulty recognizing facial expressions as compo, as compared to those without pathological narcissism, difficulties with empathy.

As I said earlier, these are individuals who often can, intellectually understand the needs and feelings and states of others, but they can't feel them. They can't have emotional resonance with them. They can't share those emotional states. okay. And then difficulty managing negative emotions like sadness, envy, anger, and so on.

Daniel Knoepflmacher, MD (Host): I want to touch on something you just brought up, which was attachment, and sort of the style of relationships that people with narcissistic pathology have in their adult life. Can you describe the relationships and what it might feel like for those who are in relationships with these individuals?

Diana Diamond, PhD: Yeah, so This is my particular interest. it used to be Freud said, that individuals with pathological narcissism or narcissistic individuals didn't form attachments. But we know from John Bowlby's work that there is no such thing as no attachment or that's extremely rare, maybe with children reared in the wild kind of thing.

But if there are parents and so on, the child always develops a particular kind of attachment. And so we had been giving the adult attachment interview to our. Patients in several different studies. These are borderline patients in transference focused psychotherapy. And we had been looking at their attachment status, and this is something that our research group decided to do.

We thought, well, what if we look at the attachment status of the narcissistic borderlines compared to the non narcissistic borderlines? And we did in fact find what boldy had predicted many, many years ago, that those who are those who have the narcissistic, have pathological narcissism, in addition to borderline pathology, tend to have what we call dismissing attachment.

So what dismissing attachment is, it's kind of going back and forth between delegating, dismissal of others, and brittle idealization of them. Now this is exactly what we find Narcissistic patients. they often have kind of a cool contemptuous attitude about attachment, attachment relationships, attachment experiences.

they tend to valorize their own individual strengths and autonomy, tremendous difficulties with dependency. And so this was kind of a revelation for me, when we did these studies on attachment and borderline pathology and other people have also been doing such studies with the adult attachment interview and other, attachment measures.

And, it's the dismissing attachment is not the only attachment. Uh, Organization that you see in narcissistic patients. Sometimes you see that they go back and forth between dismissing others and then being preoccupied with a lot of involving anger towards them. And this is called, and the attachment system cannot classify because they can't develop any consistent representational state towards attachment figures.

They tend to ricochet back and forth. Now, this would map onto the oscillation between grandiosity and vulnerability that we tend to see in narcissistic patients. and. even those who are high functioning tend to have those oscillations. And we know this because we've looked at, individuals who have smartphones or iPads and they're asked to record as they go through their day and they have encounters with others.

what is their mental state and is it vulnerable pri primarily or grandiose? And we find that individuals, even high functioning, narcissistic individuals, if they're met with unfriendly, rejecting, challenging attitudes by others will revert to a vulnerable self state. But if they're met with approval and admiration, the grand of self state holds up.

So that going back and forth that we saw with those with, our N-P-D-B-P-D patients, those with borderline and narcissistic pathology, Really mapped onto how we think about narcissism as an oscillating, state between grandiosity and vulnerability. now in terms of treatment, which you asked about, and relationships, this very, very much affects the transference with these patients.

they tend to be off the bat devaluing of their therapist or highly idealizing. one usually predominance and it's often a rigid stance in relation to the therapist. The thera when they're devaluing and when they're withdrawn and they have a cool contemptuous attitude towards treatment. it's very difficult for the therapist to not.

react with, devaluation in turn towards the patient and want to get rid of the patient or dismiss the patient just as they're feeling dismissed. But if you understand that this is part of their attachment configuration, I think it makes it much easier to work with these patients because you understand that that's a defensive posture and it may take a very long time to establish the relationship.

But the important thing is to stay with the patient and not, devalue the patient reactively, or not to, interpret prematurely, or call attention to oneself in the room because one is feeling so dismissed. in our supervision groups, people often say, I feel like there's nothing happening.

Like, I'm not even in the room. The person isn't even listening to me. This is dismissing attachment. And so if they understand it as an attachment style, you see, it makes it much easier to work with these individuals.

Daniel Knoepflmacher, MD (Host): That tracks, I imagine for how a lot of those in their life feel dismissed. You, turn to, treatments and I want to ask you about the treatments that are out there, obviously. We, you're going to tell me a lot about, transference focused psychotherapy. 'cause that's where your expertise is, that's what your book is specifically describing.

But can you, before you do that, tell me a little bit about the different options and then, tell me specifically a bit about, transference focused psychotherapy.

Diana Diamond, PhD: Well, yes. So let me just say a word about transference focused psychotherapy first and why I think it's uniquely suited to treat those with pathological narcissism. first of all, it focuses on bringing about change, not just in symptoms, but in psychological structure. So those maladaptive mental representations we were talking about that go into comprising the grandiose self.

and the dismissing attachment status are things that get addressed. There's structure and limit setting. This is really important for narcissistic patients. We talked about the difficulties with, the risk of suicide. So having a treatment contract where Self-destructive, behaviors and attitudes are dealt with.

right off the bat is a really, I think an seen a qua of working with a narcissistic patient, particularly one who is more disturbed. and then in TFP a form of, obviously of psychotherapy. We have the face-to-face interaction and also the here and now of the focus on the, what's going on in the transference from moment to moment with the therapist.

So this counterbalances that dismissing detachment of the narcissistic patient and their emotional disengagement because we're calling attention to what's going on in the transference from moment to moment. And this builds the relationship. so TFP activates the attachment and other motivational systems, and.

We're looking at, particularly those internal representations and behaviors that are related to grandiosity and vulnerability. And the goal really is the dissolution of the grandiose self as those ideal and devalued, self and other representations get reflected on and interpreted and worked with in the here and now of the transference.

Now, with that said, so I should back up and really say there really are no evidence-based treatments for NPD. Or pathological narcissism. So what a number of groups have done, because there are so many patients out there who need treatment, is we've adapted near n neighbor treatments like, evidence-based treatments for BPD, which transference focused psychotherapy happens to be one of four evidence-based treatments.

And we've adapted those to meet the needs of narcissistic patients. So our group has done that, but also there are other treatments that have done that. probably the primary, well there's two primary other treatments that I think, people should be aware of. One is schema focus therapy and schema focused therapy is interestingly enough, borrows very heavily from Kernberg's work on object relations as being underlying pathology, underlying symptoms and so on.

And it really targeted. Specific object relational scenarios, images of self and other in their interaction that they have found to be characteristic of those with narcissistic pathology. like, the individual is mistrusting other and the other is seen as abusive. They're a little different.

their focus is a little bit different because it's more cognitive, number one. And it also focuses on what they call re-parenting, where the individual, the therapist is really offering the individual a chance to almost, Experience, re experience their childhood in vivo with the therapist, and to work very actively with these schemas.

And the schemas are also preset. They have a set number of schemas that they believe go along with narcissistic pathology. so schema focused therapy, and actually I think it has good, very rudimentary research, but so far the research looks good. the other form of treatment is, mentalization based treatment.

And MBT also, goes about treating narcissistic pathology somewhat different. Lee. it really helps the person to understand the mental states that are associated with grandiosity and vulnerability, and how they might oscillate back and forth between those mental states. And, To really reflect on those mental states, not work with them in the transference the way TFP does, but asking them to reflect on them and through becoming more aware of when the conditions under which they get into those mental states, what is the impact on their lives, et cetera, et cetera.

they believe that through learning how to mentalize and the therapist is very active in sharing their own processes of reflection as well, that they believe that then the grandiosity can be resolved. I should mention, however, that MBT does also talk about grandiosity as being kind of a squon of narcissistic pathology.

so these are treatments that I think both of which have, I know MBT, there's now a book out on mentalization based treatment for narcissistic pathology. I don't know about schema, but I know there's a number of articles.

Daniel Knoepflmacher, MD (Host): I'm curious, is there ongoing research in all three that you know of?

Diana Diamond, PhD: Yes. There's ongoing research in all three treatments. I think that because there currently are no evidence-based treatments specifically for N-B-D-N-P-D, people are very involved in, in beginning to do research, like for example. We don't have a particular clinical trial in transference focused psychotherapy, but we have two clinical trials, with a third on the way, and then a couple of naturalistic studies that look at change in borderline patients.

Over the course of, most of our studies are 12 months. We are now doing an 18 month study, so that's a study in process, but we are looking at. Those patients who have NPD and BPD and those comprise anywhere from 10% to 70% of the patients in our studies. And those patients have fared well actually in TFP, first of all, in our US clinical trial, they have lower rates of dropout than do the, straight BPD patients.

they, along with the BPD patients, were found to change in attachment security. So changing from unresolved, or disorganized or insecure attachment to secure attachment, we found in one study also changes major changes in their capacity to mentalize, which is really interesting because we don't focus on mentalization per se.

We focus on interpreting the self and object. Representations that emerge particularly in the transference relationship, but also in other relationships and working with those as they are split and polarized, trying to work towards further integration of both those representations and the ethic states, the polarized ethic states that are connected to them.

And so we do find improvement in mentalization that occurs, even though the treatment isn't specifically targeting mentalization, which is really very interesting. So changes in attachment security, changes in mentalization, changes in symptoms including self-destructive symptoms and suicidality and changes, major changes in social functioning.

Daniel Knoepflmacher, MD (Host): I want to ask you about one piece of that, the, combo of the N-P-D-B-P-D patients, that there's actually more adherence to treatment among those who have some narcissistic pathology versus those who are borderline personality disorder diagnosis without the narcissistic pathology. How do you account for that?

Diana Diamond, PhD: Well, less dropout.

Daniel Knoepflmacher, MD (Host): Right? So, why do you think there's less dropout?

Diana Diamond, PhD: Well, I think these patients, you know, when we've presented this, we presented the, some of these data at the American psychoanalytic one year and somebody said, oh, well maybe our goals related to change our borderlines into narcissistic patients. and it may be that borderline patients do go through, a phase of, organizing around a grandiose self.

Or conversely, we see narcissistic patients as they get deeper into treatment, looking more borderline as their narcissistic defenses are addressed and challenged and worked with. but I think it's because these patients have a more stable structure. I think the grandiose self confers more stability.

In an odd way. So for example, we looked at rates of trauma in those with N-P-D-B-P-D and those who just had BPD, and we actually found that this is in our US randomized clinical trial that was headed by John Clark and, Ken Levy. And what we found was very interesting. We found that they didn't have, different rates of trauma, so they had equal rates of trauma if we looked at a questionnaire of trauma.

But on the adult attachment interview, those N-P-D-B-P-D patients did not show as much what we call lack of resolution of trauma and loss. So that's very interesting because it shows that maybe these patients have more ego resources you see in the face of trauma. And there's another interesting finding that we're finding in our more recent clinical trial, which is those with malignant narcissism or features of malignant narcissism do tend to have more lack of resolution of trauma.

So this may be telling us something about developmentally, about what predisposes an individual to malignant narcissism. It may be, trauma and lack of resolution of it.

Daniel Knoepflmacher, MD (Host): Diana, I could talk a lot more about all of the research that you, have done as, part of PDI and others.

And, this is an endlessly interesting topic, but want to actually switch to something we started with, which is what's going on in our culture and. I'm curious if you have thoughts on why, there is so much growing interest in narcissism and narcissistic personality disorder or pathological narcissism in our culture.

And, do you actually think there is an increase in narcissism generationally that is going on right now?

Diana Diamond, PhD: there are different views of this, and different, research data on it actually. So, there was that group, twinge, I think, Jean t Twinge and Campbell and T Twinge who have written, you know, they've been surveying college students. I think from the 1980s on, and they did with something called the pathological narcissism inventory that has no clinical cutoffs.

It just rates narcissistic traits. And they actually found that the rates of narcissism in college students have been increasing incrementally since the 1980s. And in fact, that they now are at the level of what they find in most celebrities. now there's another group that's been surveying college students that has challenged these findings and said, no, actually, college students are much more concerned about the environment, volunteering, pro-social behavior, and they're not necessarily more narcissistic.

I think there's, Statistical research data, which is somewhat contradictory, but then there's the clinical data. And I think all of these treatments for narcissistic pathology would not be in process of development. And there wouldn't be so much interest in it if there weren't many more patients who are coming with either traits of pathological narcissism or actual full blown narcissistic personality disorder.

And so the way I would answer that question is yes, I do think there's a change in the dominant personality type of our time. now with that said, and I think that looking at narcissism through a clinical lens can help us develop a perspective on individuals whose behavior is narcissistic in a more ameliorated way.

and. there's no doubt that traits like self-centeredness, social dominance, independence and that fear of dependency, attention seeking, that these are social, culturally sanctioned in our time. That these lead to self enhancing and self-promoting behaviors and attitudes in the general population, and that they are having some impact on the general capacity for in-depth relatedness, intimacy and so on.

And, even the capacity to love, you know, but I have a somewhat different view of that. I don't think that a narcissistic society inevitably will create narcissistic pathology in its citizens because I think we have to look at the continuities between collective narcissism and individual narcissism, but also we really have to distinguish between the two.

because I think narcissistic traits don't automatically involve, The development of a narcissistic personality disorder. I have quite a few patients who have narcissistic traits. They're very ambitious, even in a cutthroat way. They are extremely, self-centered. they are obsessed with their image and with externals and so on, and yet these are people who still have the capacity to invest deeply in relationships with others.

Have very deep, intimate, capable of deep, intimate relationships with partners, spouses, children. And so on. So we have to really distinguish between narcissistic traits in the general society, which society does foster those traits. I mean, the rise of influencer as a profession is kind of an astonishing development over the last 10 years.

There are people who basically make a living and not just a living. They make, many thousands and sometimes even in the millions of dollars, advertising themselves. Advertising products through themselves on Instagram or other social media platforms. so yes, we are living in a culture that certainly fosters narcissistic traits, but that doesn't mean that the basic inherent capacity for intersubjectivity reciprocity is going to be eliminated.

And I think that, if you look at all the mother infant research on intersubjectivity, it's undeniable that we are intersubjective beings. And the birth of that, the origins of that, the dawn of that are being pushed early and earlier in development. so really from birth on, individuals are predisposed to seek out objects, to respond to others, to respond to facial expressions, to imitate facial expressions.

Four months, Beatrice Bebe finds, synchronous or asynchronous vocalizations between mothers and infants. So, I think that we are hardwired to be intersubjective beings. And, it's really interesting because I was at a conference, I'm on the Margaret Mahler Foundation and there was a conference on cross-cultural views of Mahler and all psychoanalyst and psychologists and developmental psychologists were talking about intersubjectivity and how Mahler was wrong about her autistic phase, early autistic phase.

And that, were hardwired to be intersubjective from birth on. And there were some infant researchers there. But interestingly enough, there were two anthropologists and the anthropologists were talking about. Our culture as being a narcissistic culture and individuals being more narcissistic.

And I thought that was such an interesting, discrepancy, from the anthropologists who were looking at social. Collective narcissism and the individual developmental psychologists who were looking at intersubjectivity from birth on and how, and they were critiquing Mahler's formulations on that basis.

So I think that it's just really important to be thinking about how we can foster as clinicians intersubjectivity. And here I do want to come back to transference focused psychotherapy because the face-to-face interaction and the emphasis on the here and now of the relationship with the therapist and what the individual is experiencing, the particular object relation that's being activated, that is the representation of the self.

And how the representation of the other and the linking affect, that might be activated in the here and now, really fosters an intersubjective experience. It fosters an experience of having the person both reflect on their own internal world and how they're bringing that to relationships and to modify that entrepreneur world through the transference relationship with the therapist.

Daniel Knoepflmacher, MD (Host): Well, I do think that a lot of what Lasch was already talking about in the late 1970s and has only continued and, our, I. Interpersonal connections have been mediated more and more by technology. And there is a question about how that affects our intercept subjectivity and the way in which we're interacting with others.

But hopefully, I like your hopeful way of, looking at this, that these are narcissistic traits. We are not fully diagnosed as a society as having pathological narcissism yet. So there's hope. We have to work towards not letting that happen. So, Diana, I really want to thank you for, coming on today and, speaking with me, delving into this important topic that really deserves our attention.

You and your colleagues are doing really impressive work, pioneering, Treatment and studies that, help us understand narcissistic pathology and how, to address this condition in people who are, plagued by, narcissistic pathology. For those who want to learn more about the treatment of narcissistic pathology, specifically, using TFP, be sure to look at Diana's book, treating pathological narcissism with transference focused psychotherapy.

So thank you so much for taking the time to speak with me today.

Diana Diamond, PhD: Thank you for inviting me, Daniel. It was. A really a pleasure and a privilege to be on this podcast.

Daniel Knoepflmacher, MD (Host): The privilege is all mine. So thank you and thank you to all who listen to this episode of On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on many major audio streaming platforms, including Spotify, apple Podcasts, YouTube, and iHeartRadio.

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