Psychiatry | Narcissism: Always the last word

Many people are accused of being narcissists—currently by Donald Trump. What do you say to that?

The term "narcissist" is not a protected term. It is commonly used to describe people who are extremely self-confident, arrogant, and selfish. It is understandable that Donald Trump is labeled this way, as he displays the personality traits of narcissism to their fullest extent. These include self-idealization, arrogance, entitlement, and a lack of empathy . Nevertheless, one should not assume that he has a personality disorder.

When do we speak of a narcissistic personality disorder?

The essential criterion is that the person in question suffers from it. That is not the case with Trump. First of all: every healthy person has narcissistic personality traits. Everyone wants to be the center of attention, to be successful, to be valued, perhaps even admired. You can compare it to blood pressure: everyone has blood pressure, but it only becomes problematic when it is consistently too high. In relation to narcissism, the question is: How pronounced are these traits? An important characteristic of the disorder is that someone has extremely narcissistic traits but is unable to regulate them in a way that maintains psychological stability. If you constantly idealize yourself, always have a sense of entitlement, always want to be the better person, then you will experience negative social consequences. That means you will be abandoned by your partner or have conflicts with colleagues. That is when the suffering begins.

Let's assume someone is suffering because relationships never work out. How much does this person connect this to their narcissistic traits? How much insight into their illness is there?

This is often a problem. Roughly estimated, 50 percent of those affected say, "It's the other people's fault; I'm doing everything right." But there are also those who are fully aware of their narcissistic traits but are unable to address them. One of my patients once said, "I always need to have the last word. I know that's hard for others to bear—but it's just the way it is, and I don't know why."

What is the deciding factor for those affected to come to you?

Most come because of comorbidities such as depression or anxiety disorders. It is then discovered that these illnesses originated from a psychological problem. Some are in crisis, perhaps because they have been fired or their relationship has been unilaterally ended. Others are referred by their partners. Apart from that, there are also some who somehow already know what's wrong with them and come for that reason alone.

Is it true that narcissists are mostly men?

Yes and no. Recent studies show that while there are slightly more narcissistic men, the differences are very small. Narcissism may manifest itself slightly differently in women . But actually, there are no drastic differences between the sexes.

To what extent does the phenomenon appear different in women?

Women more often display their narcissism by focusing on attractiveness or appearance, while men are more concerned with status and success. Furthermore, there are two forms of narcissism that may differ between the sexes. The grandiose type has a grandiose side and a vulnerable side. They do everything they can to gain recognition and praise because they have a damaged self characterized by shame, loneliness, and fear. They compensate for this low self-esteem by attracting a lot of attention. This is the side that is visible to the outside world. Vulnerable narcissism must be distinguished from this. These are people who appear rather modest and inconspicuous on the outside. However, upon getting to know them better, they clearly exhibit narcissistic traits such as self-idealization, high standards, and little empathy for others. They hide these characteristics because they fear negative consequences. The question is whether this form is more common in women. However, there are not enough studies on this yet.

Lack of empathy is a key characteristic of narcissism. How does it come about?

Several studies have shown that narcissists don't want close contact with other people. For several reasons. The first is that it doesn't fulfill their narcissistic needs. It's like this: What do I gain from empathizing with another person? The second is that narcissistic people shy away from closeness. Anything involving emotions, including sensitivity and weaknesses, is foreign and uncomfortable to those affected. They want to appear strong, dominant, and successful. That's why they have no use for empathy. After all, empathy means getting close to another person.

Can you learn this?

It's difficult to train feelings directly. But empathy is also a cognitive matter – it's also about mentally engaging with the needs of other people. This is trained in psychotherapy by always asking patients in conflict situations: Why did the other person react that way? What did they actually need? This constant change of perspective is an essential part of psychotherapy. Those affected should realize that if they don't recognize another person's needs, they will oppose their needs. In other words, they are essentially shooting themselves in the foot. Only when they learn to recognize other people's needs will they be more accommodating.

Is narcissistic personality disorder difficult to treat?

Personality disorders are generally difficult to treat because, as the name suggests, they affect the entire personality. You should never assume that those affected will fundamentally change. What I always convey at the beginning of therapy is that 70 or 80 percent of their personality is perfectly fine. It's okay to drive a Porsche, be loud in public, and so on. What ultimately causes problems is the remaining 20 to 30 percent. I also say: If you're willing to pay more attention to your wife's or husband's needs, you don't have to change much. But if you can do that, your relationship will stabilize.

What about caregivers? Can friends and partners learn how to deal with those affected as effectively as possible?

Yes, that's a big challenge. Basically, there are three options: The first option is to break up. The second strategy is to say, "I can just handle it. I'll accept that my husband or wife has this attitude and stop trying to fight it." The third option—and this is the most complicated—is to try to work on the relationship. There are a few strategies, such as trying to avoid emotional discussions and instead always highlighting commonalities.