What is empathetic impairment in narcissistic personality disorder?

12 min readAug 10, 2020

If you are over the age of 25 and living in an overpopulated planet called earth, chances are you have dealt with people with NPD (narcissistic personality disorder) directly or indirectly. Moreover, you have been befuddled with the nature of human empathy.

Do we understand empathy? Is it an emotion? Is it a thought? Is it linked to morality, ethics or how we live our lives? Is it a product of our own conditioning? Is it a social mask we wear, a currency? Or is it the holy grail of the human soul?

We live in a more and more divided society where the suffering of narcissim from our own, or from others have become an epedemic; however, we do not understand what is our empathetic functioning.

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Philosophy aside, being a diligent psychology student as I am; I conducted my own research into how to understand empathy from a biological and a behavioural approach, and I intend to shed some lights towards the problem of empathy within NPD (narcissist personality disorder)- a more and more severe mental disorder that affects about 6% in the population (Stinson et al., 2008). And it is way more complicated than just“an emotional problem”.

American Psychiatric Association described a person with narcissistic personality disorder (NPD) as showing a prevalent pattern of grandiosity, lack of empathy, and a perpetual need for attention.

There have been numerous findings indicating the negative correlation between narcissism and empathy. (Watson et al., 1984; Watson and Morris, 1991; Watson et al., 1992). “Lack of empathy” has been one of the most crucial criterions for diagnosing NPD according to the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V).

However, such an explanation in DSM-V manual lacks sufficient empirical researches, and the instruction in the manual was purely built on expert consensus and clinical inspection(Millon, 1983) for NPD. We need to equip ourselves with more updated research-backed knowledge and an in-depth understanding on empathetic functioning if we want to truly understand narcissism.

Let’s look at the following researches that employed different methods — electrophysiological measures: EEG, neurophysiological measures- fMRI, as well as behavioral measures to examine the nature of empathic functioning on a biological and cognitive level among NPD patients. Some of which provided for the first time empirical findings of this subject.

Behavioral measure

Marissen, M., Deen, M., & Franken, I. (2012). Disturbed emotion recognition in patients with narcissistic personality disorder. Psychiatry Research, 198(2), 269–273.

This study set out to provide the first empirical assessment regarding cognitive and emotional empathy in NPD patients.

Forty-seven patients with clinically diagnosed NPD, 27 with clinically diagnosed borderline personality disorder (BPD)(without comorbid NPD), and 53 (HC) healthy controls were recruited in the study.

The study provided the first empirical evidence that NPD has unaffected cognitive empathy but impaired emotional empathy comparing to HC. This result was consistent with a recent study with NPD patients (Ritter et al., 2011). Moreover, the study produced an interesting finding in that BPD, as another personality disorder from cluster B, has a reversed deficit in the empathy category- significant impairment of cognitive empathy and unaffected emotional empathy.

The Interpersonal Reactivity Index (IRI; Davis,1980); Multifaceted Empathy Test (MET) as well as Movie for the Assessment of Social Cognition (MASC) were employed in the study to measure emotional and cognitive empathy.

Same as the other two studies, the perspective-taking (PT) and empathic concern (EC) sub-scores in the IRI measures cognitive empathy, emotional empathy, respectively. PT measures the capability to mentally understand another individual’s point of view. An example of it is: “Before criticizing somebody, I try to imagine how I would feel if I were in their place.” EC means the ability to feel sympathy for others. An example of this is: “When I see someone being taken advantage of, I feel kind of protective towards them.”

Interestingly enough, the result from the IRI indicated that self-reporting, NPD patients do not have impaired emotional empathy(P=0.11, ω2=0.02); however, they reported having lower cognitive empathy (P<0.05, ω2=0.08).

The purpose of the MET test were two folds; firstly, it measures the cognitive empathy level of the participants by asking them to define the mental state of visual stimuli from a list of four choices. Secondly, it measures the emotional empathy level of the participants by asking them to rate the degree to which they can cognitively relate to the feeling of the visual stimuli, as well as the degree of empathetic concern they can feel towards the stimuli and the test subjects. Taking the test’s subscales (cognitive empathy, emotional concern, emotional mirroring) as dependent variables, the result indicated there is a significant difference between two groups for emotional concern(F2, 95 = 25.41, P<0.05, ω2= 0.20); as well as emotional mirroring (F2, 95 = 23.70, P<0.05, ω2= 0.19), which are the two measurement sub-scales for emotional empathy capacity. This contrasted NPD’s self-reporting evaluation.

MASC tests were also employed to assess the cognitive empathy level of the participants by asking them to choose a correct answer, several times, about the actors’ intentions, thoughts, and feelings within a film of 15min movies. The result suggested only significant differences between patients with BPD and HC (P = 0.011), but not between NPD and HC (p=0.22).

The study provided the sufficient empirical evidence that NPD has unaffected cognitive empathy but impaired emotional empathy comparing to HC, which answered the first part of our question in terms of the cognitive and behavioural differences among NPD patients influencing their capacity of empathy. This result was consistent with a recent study with NPD patients (Ritter et al., 2011).

The behavioral methods used in this study is very comprehensive. The MET test and the MASC test investigated different sub-categories of empathy: emotional concern and emotional mirroring that represents emotional empathy, and cognitive empathy. According to the result of their self-reported questionnaire (IRI), NPD believes they have inferior cognitive empathy. However, the result from the study showed a clear indication that it is not due to a cognitive deficit in understanding but an inferior emotional concern for others in pain that NPD’s lack of empathy is more accurately summarised. This suggests the description of the lack of empathy trait of NPD in DSM-V: their unwillingness to identify and mentally understand the feelings and needs of others(American Psychiatric Association, 2000) could be subject to further research and improvement, as well as therapeutic treatment that focuses on cognitive empathy.

The diagnostic criteria of NPD in DSM-V propounded the lack of empathy is due to their unwillingness to identify and mentally understand the feelings and needs of others. However, the present study opposed such conclusions in that it is not due to a motivational deficit to understand others, but an inferior emotional concern for others.

2. Electrophysiological measures

Marcoux, L.-A., Michon, P.-E., Voisin, J.I.A., Lemelin, S., Vachon-Presseau, E., Jackson,P.L., 2013. The modulation of somatosensory resonance by psychopathic traits and empathy. Frontiers in Human Neuroscience 7, 1–13.

Previous neuroimaging studies on pain observation indicated there is a neuronal pathway between the perception of pain in others and the perception of pain in self- an automatic resonance mechanism (Decety & Jackson, 2004). The working of this mechanism was further interpreted as from lower-level vicarious pain response from observing others in pain to a higher-level cognitive process to develop empathetic concern and empathetic function (Marcoux et al., 2013).

The current study investigated the vicarious pain response by measuring the neuronal response to observing physical pain infliction on another person between NPD (n=13) and healthy controls (HC, n=11).

EEG data from quantitative sensory testing (QST) yielded two major conclusions:

NPD displayed a significantly higher degree of pain pressure thresholds (PPT) than HC: (p=0.024, α=0.05).
Only NPD had a more significant variance of the response of somatosensory gating (SG) during the anticipation and the observation phases of pain inflicted on others, between neutral and pain condition(p=0.02), and between neutral and no-pain condition (p=0.03).

The Psychopathic Personality Inventory (PPI-R) (Lilienfeld and Widows, 2005) was employed to measure the main traits of psychopathy. The result served as behavior data for the study, which indicated that the psychopathy score is significantly higher in the NPD group than in the HC group (p=0.001, α=0.05). Furthermore, it suggested that score on the Impulsivity– Egocentricity sub-scale and the Fearlessness-Dominance sub-scales were significantly higher in NPD than in HC: (p=0.001, α=0.02) and(p=0.001, α=0.025) respectively.

By analyzing the correlation between behavioral data and the EEG data, the study concluded three significant positive correlations between:

SG and PPI-R global scores was found: (r= 0.424, p=0.039)
SG and Impulsivity–Egocentricity sub-scale scores (r=0.488, p =0.015).
The pressure pain threshold and the Fearlessness- Dominance sub-scale score (r=0.444, p=0.030).

These combined findings suggested that patients with higher narcissistic traits have stronger somatosensory resonance to pain and an increased degree of attention when observing pain inflicted on another person, indicating higher vicarious pain resonance. At first glance, such a result would seem counter-intuitive. However, Decety & Svetlova (2012) suggested that this somatosensory response while seeing others in pain could activate distress and threat-related networks. To reach homeostasis, regulation processes of such responses are obligatory within an individual to develop higher-order empathy. The above findings present to us a possible focus of hypothesis to be further researched upon. The regulation process of this automatic response system among NPD patients could be somehow impaired compared to HC, which prevents them from evolving from a lower level of vicarious pain response to a higher-order empathetic functioning while viewing others in pain.

The EEG measures in the current study produced excellent temporal resolution data; this is a good point since we can instantly see how the brain responds to various stimuli. However, it could generate poor spatial resolution data, which means we are not entirely sure where these brainwaves are originating from.

The regulation process of this automatic response system among NPD patients could be somehow impaired compared to HC, which prevents them from evolving from a lower level of vicarious pain response to a higher-order empathetic functioning while viewing others in pain.

3. Neurophysiological measures

Schulze, L., Dziobek, I., Vater, A., Heekeren, H., Bajbouj, M., & Renneberg, B. et al. (2013). Gray matter abnormalities in patients with narcissistic personality disorder. Journal Of Psychiatric Research, 47(10), 1363–1369.

The study built on the identification of the potential neurological correlation between insular cortex features and impairments in empathy. (Decety & Lamm, 2006 ; Singer & Lamm, 2009). Using neurophysiological measures, it calculated and compared the gray matter abnormalities in the anterior insular part of NPD patients and healthy controls (HC).

The study built neurobiological evidence that lack of empathy can be traced back to a smaller grey matter volume in the left anterior insula. It pointed to the direction of further neurobiological research of NPD.

Seventeen patients with clinically diagnosed NPD and 17 healthy controls participated in the study.

The Interpersonal Reactivity Index (IRI; Davis, 1980) was employed as a self-report tool; the score indicated that NPD patients exhibited deficits for cognitive empathy comparing to HC; However, it was not significant. (t30=2.08, p=0.05)

A 1.5T scanner was employed to obtain Magnetic resonance imaging (MRI) data, which were then processed by VBM toolbox.

Two sample t-tests were conducted to compare the global volumes of four categories: gray matter(GM), cerebrospinal fluid, white matter, and the total intracranial volume between healthy controls and NPD patients. GM volumes in the left anterior insula were smaller among NPD patients than HC (T =3.32, p < 0.05). A non-significant smaller effect was also found in the right anterior insula (T =3.01, p < 0.10). Regression analyses indicated a positive correlation between the GM volume of the left anterior insula and the self-reported emotional empathy sub-score from IRI. (T =3.01, p < .10 , r=0.62)

The study built neurobiological evidence that lack of empathy can be traced back to a smaller GM volume in the left anterior insula. It pointed to the direction of further neurobiological research of NPD.

The MRI method used in this study does present certain limitations. The principle MRI technique measures blood oxygen level dependence. This technique does not confirm direct causality between neuronal activity and the result from the MRI machine. Furthermore, the sample size of 34 patients was at the lowest limitation of VBM toolbox admission. This relative small sample size exposed the result to a greater risk of defining the existence of an effect. Moreover, there was no experimental design in this study; one could argue that the abnormalities in the left anterior insula among NPD patients are linked with other NPD traits such as dysregulation of one’s self-esteem, hypersensitivity to criticism, grandiosity, and self-referential processing biases (American Psychiatric Association, 2013).

Conclusion

The behavioral study result indicated a possible focus for future research: How do we investigate the lack of emotional empathy among NPD? The EEG study results suggested that we could look into how their regulatory process from lower-level vicarious pain resonance to higher-order empathy development is impaired.

As prevailing as it is in the western culture, knowledge about the etiology, course, and treatment of NPD are unsatisfactory. This literature review focuses on the empathic capacity in NPD. In a personal development context, an individual’s empathy capacity has a strong influence over his or her overall happiness level in society, and it’s an integral part of his or her emotional intelligence. However, human’s capacity of empathy is more complicated than a pure emotional attribute. It involves more complex cognitive aspects, such as perspective-taking (Mutschler et al., 2013). The three studies included in this review offered us empirical evidence on the complicated nature of empathy in NPD patients using different methods in biological and cognitive psychology domains. From a biological level, study 2 and study 3 showed us that empathy strongly correlates to the left anterior insula; NPD patients have stronger somatosensory resonance to pain and an increased degree of attention when observing pain inflicted on another person. It echos with the behavioral evidence in study 1 that NPD patients’ mental and cognitive ability to observe and process pain is not impaired. However, since there is a lack of interest in sympathize with another person’s pain, their emotional empathy capacity is significantly inferior. In other words, knowing but not caring might be the more appropriate description of such personality disorder. They do not lack in cognitive ability required for understanding the needs and feelings of others. However, the lacking is significantly in their capability to respond to another person’s emotional state emotionally.

The behavioral study result indicated a possible focus for future research: How do we investigate the lack of emotional empathy among NPD? The EEG study results suggested that we could look into how their regulatory process from lower-level vicarious pain resonance to higher-order empathy development is impaired.

Combining functional MRI methods with experimental paradigms, further research could investigate the regulatory processes, self-referential processes, and decision-making processes among patients with NPD as it pertains to their empathetic functioning. This will represent a comprehensive approach to deepen our understanding of the latter subject.

References:

Blair, R.J., 2005. Responding to the emotions of others: dissociating forms of empathy through the study of typical and psychiatric populations. Conscious- ness and Cognition 4, 698–718.

Davis, M.H., 1980. A multidimensional approach to individual differences in empathy. JSAS Catalogue of Selected Documents in Psychology 10, 85.

Decety J, Lamm C (2006). Human empathy through the lens of social neuroscience. Scientific World Journal 6, 1146–1163.

Fan Y, Wonneberger C, Enzi B, de Greck M, Ulrich C, Tempelmann C, et al. The narcissistic self and its psychological and neural correlates: an exploratory fMRI study. Psychologie Medicale 2011;41:1641–50.

Fecteau, S., Pascual-Leone, A., Theoret, H., 2008. Psychopathy and the mirror neuron system: preliminary findings from a non-psychiatric sample. Psychiatry Research 160, 137–144.

Kohut, H., 1966. Forms and transformations of narcissism. Journal of the American Psychoanalytic Association 14, 243–272.

Lilienfeld, S.O., Widows, M.R., 2005. Psychopathic Personality Inventory — Revised: Professional Manual. Psychological Assessment Resources Inc., Odessa, FL.

Marcoux, L., Michon, P., Lemelin, S., Voisin, J., Vachon-Presseau, E., & Jackson, P. (2014). Feeling but not caring: Empathic alteration in narcissistic men with high psychopathic traits. Psychiatry Research: Neuroimaging, 224(3), 341–348.

Marissen, M., Deen, M., & Franken, I. (2012). Disturbed emotion recognition in patients with narcissistic personality disorder. Psychiatry Research, 198(2), 269–273.

Millon, T., 1983. The DSM-III. An insider’s perspective. American Psychologist 38,804–814.

Mutschler, I., Reinbold, C., Wankerl, J., Seifritz, E., & Ball, T. (2013). Structural basis of empathy and the domain general region in the anterior insular cortex. Frontiers In Human Neuroscience, 7.

Ritter, K., Dziobek, I., Preissler, S., Rüter, A., Vater, A., Fydrich, T., Lammers, C.H., Heekeren, H.R., Roepke, S., 2011. Lack of empathy in patients with narcissistic personality disorder. Psychiatry Research 187, 241–247.

Ritter K, Roepke S, Merkl A, Heuser I, Fydrich T, Lammers CH. Comorbidity in patients with narcissistic personality disorder in comparison to patients with borderline personality disorder. Psychotherapie Psychosomatik Medizinische Psychologie 2010;60:14–24.

Ronningstam, E., 2005. Narcissistic personality disorder: a review. In: Maj, M., Akiskal, H.S., Mezzich, J.E., Okasha, A. (Eds.), Personality Disorders. John Wiley & Sons, Hoboken, NJ, pp. 277–327.

Singer T, Lamm C (2009). The social neuroscience of empathy. Annals of the New York Academy of Sciences 1156, 81–96.

Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry 2008;69:1033–45.

Watson, P.J., Grisham, S.O., Trotter, M.V., Biderman, M.D., 1984. Narcissism and empathy: validity evidence for the narcissistic personality inventory. Journal of Personality Assessment 48, 301–305.

Watson, P.J., Little, T., Sawrie, S.M., Biderman, M.D., 1992. Measures of the narcissistic personality: complexity of relationships with self-esteem and empathy. Journal of Personality Disorders 6, 433–448.

Watson, P.J., Morris, R.J., 1991. Narcissism, empathy, and social desirability. Personality and Individual Differences 12, 575–579.

What is empathetic impairment in narcissistic personality disorder?

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