A masked negative self-esteem? Implicit and explicit self-esteem in patients with Narcissistic Personality Disorder

Highlights

• The Mask model states that narcissistic behavior results from underlying ego fragility.

• NPD patients did not differ in explicit or implicit self-esteem compared to controls.

• It might be less relevant to focus NPD treatment on underlying negative self-esteem.

Abstract

The mask model of narcissism states that the narcissistic traits of patients with NPD are the result of a compensatory reaction to underlying ego fragility. This model assumes that high explicit self-esteem masks low implicit self-esteem. However, research on narcissism has predominantly focused on non-clinical participants and data derived from patients diagnosed with Narcissistic Personality Disorder (NPD) remain scarce. Therefore, the goal of the present study was to test the mask model hypothesis of narcissism among patients with NPD. Male patients with NPD were compared to patients with other PD's and healthy participants on implicit and explicit self-esteem. NPD patients did not differ in levels of explicit and implicit self-esteem compared to both the psychiatric and the healthy control group. Overall, the current study found no evidence in support of the mask model of narcissism among a clinical group. This implicates that it might not be relevant for clinicians to focus treatment of NPD on an underlying negative self-esteem.

Introduction

Although the concept of narcissism has intrigued clinicians, theorists, and scientists for many decades, the Narcissistic Personality Disorder (NPD; DSM-5, APA, 2013) has received relatively little empirical attention (e.g., Roepke and Vater, 2014, Ronningstam, 2005, Ronningstam, 2010). This lack of research is problematic because patients with NPD form a difficult and challenging group to treat in clinical practice (Thomaes and Bushman, 2011). Theories and treatments of NPD are predominantly based upon clinical theories resulting from patient observations or even single case studies (Cain et al., 2008). It is often assumed that NPD symptoms originate from underlying low self-esteem (e.g. Morf and Rhodewalt), but there is a lack of empirical support for this theory among clinical samples (Cain et al., 2008, Pincus and Lukowitsky, 2010; Vater et al., 2013a. The current study therefore aims to further examine some of the most important features of patients with NPD (see Marissen et al., 2012), and examines the difference between implicit and explicit self-esteem among patients with NPD.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA, 2013), patients with NPD have a pervasive pattern of high need for admiration, grandiosity, and lack of genuine interest in others (Emmelkamp and Kamphuis, 2007, Pincus and Lukowitsky, 2010, Ronningstam, 2013). The most common view regarding the origin of narcissistic behaviors is derived from psychodynamic literature. That theory suggests that pathological narcissism is the result of an underlying fragile and unstable self-esteem (Kernberg, 1989, Kernberg, 1998, Kohut, 1968). This impaired self-esteem is believed to be caused by severe frustrations as a result of inadequate parenting in early development (Akhtar, 1989). In that view, the central feature of narcissism, presenting oneself with superb grandiosity, is explained as a strategy of defense against feelings of extreme inferiority (Akhtar and Thomson, 1982, Akhtar, 1989). More recent theories from a social psychology point of view also support the idea behind this so-called “mask” model of narcissism. According to the mask model, patients with NPD attempt to maintain a grandiose, but fragile, view of themselves. These attempts accordingly stem from the urge to mask their profound feelings of inferiority that originate from early interpersonal experiences (Morf and Rhodewalt, 2001, Tracy and Robins, 2003).

Both the psychoanalytic theories and the mask model are based upon the idea that NPD patients have an impaired self-esteem (e.g. Cain et al., 2008). To understand the concept of self-esteem, it is important to consider that there are at least two levels: Implicit and explicit self-esteem (Jordan et al., 2003, Zeigler-Hill and Jordan, 2011). Implicit self-esteem has been defined as an automatic and non-conscious evaluation of the self that guides spontaneous reaction to self-relevant stimuli (Kernis, 2006). Several studies have examined the role of both implicit and explicit self-esteem among various psychiatric disorders such as depression and anxiety disorders, however results remain inconclusive concerning the influence of implicit self-esteem on the development and maintenance of these disorders (.e.g. Franck et al., 2007a, Franck et al., 2007b, Ritter et al., 2013). The mask model of narcissism suggests a discrepancy between high overt levels of self-esteem (explicit self-esteem) and lower automatic, uncontrollable levels of self-esteem (implicit self-esteem). This type of ‘narcissistic’ self-esteem is characterized by high explicit self-esteem and low implicit self-esteem, is also referred to as ‘fragile self-esteem’ (Zeigler-Hill, 2006, Zeigler-Hill and Jordan, 2011).

To investigate the scientific evidence for the mask model of narcissism, Bosson et al. (2008) performed a meta-analysis to examine and compare studies that tested the model among non-patient groups. Overall, they found no evidence for the mask model among normal populations since no association was found between narcissistic features and the expected high explicit/low implicit self-esteem combination (Bosson et al., 2008). To our knowledge only one study has examined the mask model among patients diagnosed with NPD compared to a group of patients with Borderline personality disorder (BPD) and non-clinical controls (Vater et al., 2013a, Vater et al., 2013b). In that study it was found that, contrary to the expectations, patients with NPD reported a lower explicit self-esteem compared to a non-clinical control group. Also, no differences in implicit self-esteem were found between these groups raising serious questions about the validity of the mask model of narcissism (Vater et al., 2013a, Vater et al., 2013b).

To summarize, although influential models are based upon the believe that narcissists tend to mask their feelings of inferiority by displaying grandiose feelings of self-worth, so far no solid scientific evidence (in both non-clinical and clinical groups) can be found to support this theoretical model. There seems to be little consensus about the underlying processes in narcissism, although the view upon the origins of narcissism can have serious implications for the treatment of patients with NPD. For example, when considering a low self-esteem as the origin of narcissistic behaviors, one would aim at repairing or enhancing this self-esteem during treatment. Studies focusing on patients with NPD are scarce and not comparable in numbers to the studies regarding other personality types such as borderline personality traits or anti-social traits (e.g., Pincus and Lukowitsky, 2010, Ronningstam, 2013). Besides, researchers often use female undergraduate psychology students as participants to test their hypotheses, making it highly questionable whether these groups are comparable to patients with NPD. It is therefore important to further investigate the underlying characteristics of NPD.

Since the mask model of narcissism is hardly investigated supported by research using patients with NPD, the current study aims to further investigate this model in a NPD patient sample. To our knowledge, the study of Vater et al., 2013a, Vater et al., 2013b is the only one that examined self-esteem issues among a group of patients with NPD. In that study, for comparisons between NPD patients and non-clinical controls, half of the NPD group consists of female participants (Vater et al., 2013a, Vater et al., 2013b). That group might be less representative for NPD patient groups, as it is found that the lifetime prevalence of NPD is much higher for men than women (7.7% vs. 4.8%; APA, 2013). In a large epidemiologic study among the general population in the United States, characteristics of men and women with NPD were examined (Stinson et al., 2008). As expected, a higher prevalence of NPD for men than for women was found, but also sex-specific differences concerning mental disability between men and women. Disability was associated with NPD among men, but not among women, when other psychiatric disorders were controlled for in the analyses. The authors further suggests that NPD may have a more severe expression in men relative to women so this makes it important to take gender differences into account when examining patients with NPD.

The present study therefore further elaborates on the study of Vater et al., 2013a, Vater et al., 2013b and examines evidence for the mask model among a male NPD patient group. First, to characterize the three groups, we examined whether patients with NPD differ in the degree of self-reported narcissism and psychological complaints compared to a psychiatric control group and a healthy control group. Our main question is whether NPD patients, conform the mask model, indeed possess high explicit, but low implicit self-esteem. Levels of explicit, implicit, and discrepant self-esteem will be compared between the three groups. It is expected that NPD patients will exhibit high explicit, low implicit, and large discrepant self-esteem when compared to both control groups.