Narcissistic Patients: Understanding and Managing Feelings and Behaviors

Clinical Points

• ■ Patients with narcissistic traits are encountered commonly in primary care practices and general hospital settings.

• ■ Narcissistic patients may evoke negative feelings in their providers that can negatively impact patient care.

• ■ Understanding what drives narcissistic behavior, coupled with an awareness of the feelings typically evoked when treating these patients, will allow practitioners to better manage narcissistic individuals.

Have you ever disliked or been repulsed by a patient whom you have just met? Did he or she seem obnoxious, pompous, or entitled? Have you been amazed or embarrassed by how much hatred you felt? Have you ever worried that your negative feelings might adversely influence your management of his or her medical problems? If you have, then the following case vignette and discussion will prove useful when confronted with such patients.

CASE VIGNETTE

Mr A, a 52-year-old attorney with chronic obstructive pulmonary disease (COPD), arrived at the hospital with worsening cough, fatigue, and fever; he was found to have a COPD exacerbation and multidrug-resistant pneumonia. He was placed on a 10-day course of intravenous antibiotics. However, on the seventh day of his hospitalization, psychiatric consultation was requested when he demanded to leave the hospital against medical advice.

Within a minute of starting the interview with the consultant, Mr A asked, “What kind of watch are you wearing?” The answer was direct, “An $8 Timex.” Mr A said, gloating, “I wear a Rolex.” He went on to report that he felt frustrated by the constantly changing team of doctors. He resented having to advocate repeatedly for himself by educating staff about his medical conditions. He declared that since he was improving on antibiotics, he felt well enough to return home and care for himself. He articulated the risks of not completing a full course of antibiotics, demonstrated an understanding of potential complications, and endorsed a plan to return to the hospital for treatment if his symptoms worsened. Further, he believed that the staff was not managing his medical conditions correctly; he reported repeatedly that he knew more about COPD and pneumonia than anyone on his treatment team. He recounted all that he had accomplished in his life (eg, a successful career in law and marriage to a beautiful woman). He wished that his treaters would develop COPD so that they would be more understanding of his situation and might provide him better and more respectful care.

Mr A reiterated that he found the involvement of the psychiatry service in his case demeaning. He then refused to participate further until the consultant answered questions about her own medical history and history of adversity. When these answers were not provided, Mr A stated that he did not see the utility of prolonging a discussion with someone who did not understand his (unique) situation. The psychiatry service determined that Mr A had the capacity to leave against medical advice, and he left immediately thereafter.

Given that roughly 6% of the general population fulfills DSM-IV¹ criteria for narcissistic personality disorder,² it seems safe to assume that more than 6% of patients have narcissistic traits but fail to fulfill strict criteria for narcissistic personality disorder. Since these personality traits are common, medical practitioners interact with narcissistic patients on a weekly, if not daily, basis.³ However, well-regarded texts of general medicine fail to discuss narcissistic personality disorder or its impact on patient care.^4,5

WHAT IS NARCISSISM?

Among the many descriptive categories in psychiatric nomenclature, personality and personality disorders can be thought of as enduring patterns of perceiving, relating to, and thinking about the social environment and one’s relation to this environment.⁶ Healthy, or normative, personality traits have the evolutionary advantage of increasing social effectiveness, which, in turn, facilitates better adaptation to life stresses and greater personal and social achievements.⁷ A preponderance of certain personality characteristics has come to be thought of as maladaptive and nonadvantageous.⁶ The DSM-5⁸ defines personality disorders using specific criteria. For example, narcissistic personality disorder is characterized by the following: excessive reference to others for self-definition and regulation of self-esteem, exaggerated self-appraisal or goal-setting based on gaining approval from others, unreasonably high personal standards and seeing oneself as exceptional based on a sense of entitlement, an impaired ability to recognize or identify with the feelings and needs of others, and excessive attunement to the reactions of others, but only if perceived as relevant to oneself.⁸ Patients with narcissistic traits who may not meet the threshold for a diagnosis of narcissistic personality disorder, like Mr A, can quickly irritate and frustrate medical providers and lead to uncertainty about how best to care for these patients.

The concept of narcissism arose from the Grecian myth about a beautiful boy, Narcissus, who fell in love with himself while looking at his own reflection.⁹ Narcissus despaired when he realized he would never attain what he so deeply desired: the perfect, reflected image of himself. Throughout his struggle, he was adored by the water nymph Echo, who, because her love was unrequited, pined away and died, leaving behind only her voice. Eventually, Narcissus ended his own life, rather than accept his imperfections. As the myth reveals, the flower, known today as the narcissus, grows from the ground where his blood fell.

As reflected in the myth of Narcissus, key features of narcissism are grounded in the idea of conditional self-love: that one must be important, unique, and entitled in order to have worth. In patients with narcissistic traits, this self-view typically develops during the school-aged years and persists into adulthood. Some aspects of narcissism such as ambition and perfectionism are healthy and help individuals pursue academic and athletic achievements, as well as demanding careers. However, narcissistic defenses often strain interpersonal relationships and lead to isolation. Narcissists, by definition, require love, support, and respect from others in order to maintain their own superlative self-image. Therefore, when their own psychopathology leads to alienation from others, narcissists suffer immensely¹⁰ (eg, like Humpty Dumpty who fell off a wall and “… all the king’s horses and all the king’s men couldn’t put Humpty together again”^11(p40)). Feeling isolated, abandoned, or criticized—often by slights that others would regard as harmless—provokes narcissists to react, often to their own detriment, like when Mr A opted to leave the hospital against medical advice when he felt disrespected by staff.¹²

WHY DO SOME PEOPLE BECOME NARCISSISTS?

According to Sigmund Freud,¹³ all narcissists suffered a developmental arrest in infancy. Freud argues that infants are inherently selfish; they focus on having their needs met by others, and they alter their behavior with others so as to attain these goals.¹³ Heinz Kohut,¹⁴ another prominent psychoanalyst, proposed that the developmental arrest in infancy is due to complicated relationships between the child and his or her parents. Parents stress the importance of a child’s appearance or achievements and reinforce that the child’s sense of self is defined by comparative performance—in order to be “good,” one has to be “the best.” As the child ages, he or she places more emphasis on external presentation to avoid attention to gaps and weaknesses in his or her internal self and self-esteem. This emphasis leads the child to be highly critical of perceived imperfections, both in him or herself and in others; due to low self-esteem, there is an insatiable need to reinforce a positive self-image.

As adults, narcissists have intense cravings for love and admiration. However, feeling dependent on others makes narcissists feel weak, helpless, and inadequate. As a result, narcissists are torn between being dependent on others for love and respect, while they are simultaneously fearful of being exposed and criticized. In the case of Mr A, his physical integrity was threatened by COPD and pneumonia. Therefore, from Mr A’s point of view, his body was no longer perfect. Since he was surrounded by experts in the treatment of his illness, Mr A felt physically weaker and feared being intellectually inferior to the staff that was treating him. To reestablish dominance over those treating him, Mr A insisted on disregarding the staff’s advice and leaving the hospital, despite the risk of a poor outcome.

WHY DO NARCISSISTS BEHAVE THE WAY THEY DO?

Therapists who work with those who have narcissistic features identify 2 predominant negative emotions in these patients: shame and envy. Shame should be distinguished from guilt.¹⁵ Narcissists rarely experience guilt or behave as if they have done something wrong or badly. Rather, patients like Mr A become overwhelmed by shame, the feeling that one has been seen by others as wrong or bad. Mr A had some sense that he related poorly to the medical staff, and on his last hospital day, he insisted on disregarding medical advice, causing staff to call his capacity into question. To maintain his self-esteem and his feelings of superiority in the context of a capacity evaluation, Mr A emphasized his knowledge of his underlying illness as well as the importance of his life accomplishments.

When narcissistic patients feel deficient or inadequate they become intensely envious.^16,17 Rather than accept being surpassed by another person, they seek to destroy the attribute that threatens them (often using scorn or ridicule). Mr A attempted to belittle hospital staff by highlighting their inadequate knowledge of his illnesses and belittled his physician’s strength of character (with the assumption that the consulting psychiatrist had not overcome significant hardships). This tendency to devalue others is common in narcissists; when narcissists devalue or disregard another person or that person’s accomplishments, they feel superior to that person as well as less anxious about their own deficits. Alternatively, when narcissists idealize someone else, they illuminate their own importance by their association with this person. During his hospitalization, Mr A fluctuated frequently between idealizing and devaluing hospital staff.

HOW DO NARCISSISTS MAKE US FEEL?

Countertransference, originally a psychoanalytic concept, can be more generally defined as a medical provider’s emotional entanglement with a patient.¹⁸ Typically, a provider takes on attributes of a patient’s mother or father; however, caregivers of narcissistic patients often manifest a patient’s projections of him or herself—both the grandiose self and the deficient self.¹⁰ Staff who care for narcissistic patients frequently endorse feeling unreasonably idealized, unreasonably devalued, disregarded, invisible, bored, irritated, or impatient.¹⁰

Such feelings are common to most practitioners who care for narcissistic patients; therefore, these reactions should not be considered a consequence of a personal defect in the individual practitioner, but rather as inevitable, informative reactions to a narcissistic patient’s coping strategies. Rather than assess the rightness or wrongness of having these feelings when working with narcissists, practitioners should focus on deciphering why they feel the way they do and on how these feelings can be harnessed to better manage these patients.

During the psychiatric consultation with Mr A, there were times when the interviewer felt unreasonably idealized—“You are the first person to offer me adequate care in this hospital”—and at other times felt unreasonably devalued—“No offense, but you don’t know nearly enough about the treatment of pneumonia to offer me reasonable advice.” The emotions endured during the visit with Mr A included feeling disregarded, invisible, and irrelevant. It is unlikely that anyone in that room (male or female, young or old, short or tall) would not have noticed. Mr A forgot the consultant’s name (and her department) multiple times. He barely waited for a response to his questions before talking about something else, and he rolled his eyes when the consultant attempted to redirect the conversation.

HOW CAN WE TREAT NARCISSISTS MORE EFFECTIVELY?

While a therapeutic alliance is an essential ingredient in all successful doctor-patient interactions, it is especially important when treating a narcissist. Patients with narcissistic traits commonly terminate treatment with medical providers after incidents that providers perceive as harmless misunderstandings.¹⁰ However, to such patients, these incidents represent intolerable disrespect and incompetence on the part of their medical providers. Given that narcissists are extremely sensitive to perceived criticism or slights, it is virtually impossible for practitioners to avoid these incidents when treating such patients. Rather, it is what can be done (or not done) by a provider in the aftermath of an “insulting” incident that may determine if the doctor-patient relationship can endure.

It is important to acknowledge that, through no fault of his or her own, a practitioner may come to represent an intolerable threat to the narcissistic patient; most commonly, practitioners witness shaming incidents—however minor they may appear to observers—that narcissistic patients cannot tolerate. Termination of treatment in these cases may be inevitable, regardless of a practitioner’s efforts to reestablish trust. However, some approaches (eg, maintaining a patient, nonjudgmental, empathic attitude toward patients)¹⁰ are useful to consider and may prolong a practitioner’s alliance with such patients. Although this approach to patients may seem obvious to most medical personnel, it is particularly important when treating a narcissist—an individual who is overly sensitized to perceived criticism and incredibly good at engendering negative emotions in his or her medical providers. By understanding from where our own evoked emotions originate, we can harness our feelings and continue to treat such patients with objectivity and patience.

In addition, practitioners can model specific behaviors during clinical encounters that can be useful for narcissistic patients as well as the therapeutic alliance between patients and doctors. By modeling emotions that narcissists typically find intolerable (eg, remorse, humility, gratitude), practitioners can generate a less threatening atmosphere and demonstrate nonpathologic coping skills to these patients.¹⁰ Following an incident a narcissistic patient finds threatening, a practitioner might express remorse related to specific aspects of the interpersonal communication that the patient found painful. Admitting that one has made mistakes, while maintaining an overall positive self-image, conveys to patients that it is acceptable to make mistakes and that mistakes do not necessarily threaten one’s self-worth. In addition, apologizing for mistakes confirms a practitioner’s empathy for the real feelings of insecurity in narcissistic patients without requiring patients to (shamefully) talk about those feelings.¹⁵ Humility is another way to show a narcissistic, overly self-critical patient that you are able to discuss your shortcomings and frailty without undermining your self-esteem. Further, expressing gratitude to a patient acknowledges your nonpathologic need for—and dependency on—others. This modeling will most likely diffuse tension quickly between you and your patient and may eventually encourage these patients to take interpersonal risks of their own with you.

Direct confrontation of a narcissist’s pathologic behavior (although it may satisfy your anger, hatred, resentment) rarely helps these patients or improves your long-term relationship with them. Due to their extreme sensitivity to criticism and their tendency to relate to medical providers in comparative terms, narcissists will very likely experience direct discussions of their pathology with practitioners as hostile, demeaning, and critical. Rather than engaging narcissistic patients in a direct power struggle, providers are better served by the modeling behaviors described above.

CONCLUSIONS

Patients with narcissistic features are encountered commonly by medical practitioners in primary care practices and general hospital settings.¹⁹ These patients typically evoke negative feelings in their providers that can, in turn, negatively impact patient care. Increased awareness of our own feelings when treating these patients will allow us to better recognize the presence of narcissistic traits. This awareness, coupled with improved understanding of what drives narcissistic behavior, will allow practitioners to manage these patients more effectively in a variety of medical settings.