The word “narcissist” is used so much these days that you might think we’re in the midst of an epidemic. But pathological narcissism is not just about having an inflated ego — it’s a very serious psychological disorder. Here’s why certain people are obsessed with themselves, and the gnawing fear that drives them.

As a phenomenon, narcissism has been recognized since the time of the ancient Greeks. It was Narcissus, after all, who fell in love with his own reflection. Unable to pull away, he withered away and died.

But it wouldn’t be until 1980 when the American Psychological Association finally acknowledged it as a true pathology. Today, it’s estimated that 1 percent of the population suffers from narcissistic personality disorder (NPD), as it’s formally called, though experts believe many people go undiagnosed. Indeed, psychologists have struggled to describe, diagnose, comprehend, and treat it — which is a problem given that it’s a mental condition that appears to be increasing over time.

Thankfully, neuroscience is finally shedding some light on this largely neglected condition and its causes. It now appears that, in addition to socialization, an exaggerated fear-response is involved. What’s more, it also appears to be closely related to another interpersonal disorder: psychopathy.

More Than Just A “Big Ego” Problem

When viewed from a certain perspective, narcissism can actually be seen as a positive thing. Narcissists, are often huge performers in their professional field. As BrainBlogger Veronica Pamoukaghlian has pointed out, “their inflated sense of self-importance drives them on, to show the world just how important they really are.” Management consultant Michael Maccoby, writing in his book, notes that narcissists can be charismatic forces for change owing to their drive, vision, risk-taking, and even ruthlessness. Consequently, many corporations turn to narcissists for their leadership skills.

But narcissists can also be dangerous, reckless, self-destructive, and utterly unfun to be around. A quick scan of the DSM-IV’s description shows why:

NPD is characterized as a pervasive pattern of grandiosity, need for admiration, and lack of empathy, with interpersonal entitlement, exploitativeness, arrogance, and envy. Other notable phenotypic characteristics include interpersonal distancing and avoidance, insecurity and vulnerability, hypersensitivity, aggressivity, and proneness to shame.

The National Institutes of Health describes it as “a condition in which people have an excessive sense of self-importance, an extreme preoccupation with themselves, and lack of empathy for others.”

Indeed, as Maccoby points out, narcissists’ success feeds into their pre-existing sense of grandiosity, providing more fuel for the perception that their success was caused by their disdain for normal rules. Indeed, research has shown that narcissists are more likely to cheat in game-play and romantic relationships, take more resources for themselves and leave fewer resources for others, value material things, and be obsessively concerned with their outer appearance. Here are some other typical behaviors:

• React to criticism with rage, shame, or humiliation

• Take advantage of other people to achieve their own goals

• Have excessive feelings of self-importance

• Exaggerate achievements and talents

• Be preoccupied with fantasies of success, power, beauty, intelligence, or ideal love

• Have unreasonable expectations of favorable treatment

• Need constant attention and admiration

• Have obsessive self-interest

• Pursue mainly selfish goals

Writing in Narcissism: Behind the Mask, David Thomas, author David Thomas points out such traits as an obvious self-focus in interpersonal exchanges, problems in sustaining satisfying relationships, a lack of psychological awareness, problems distinguishing the self from others, haughty body language, hypersensitivity to insults, and many others.

One Type or More?

Amongst researchers, the standard method of diagnosing NPD is by using the Narcissistic Personality Inventory (NPI). It’s a 40-item survey that measures “normal” or “subclinical” (borderline) narcissism. It’s important to note that people who score very high on the NPI do not necessarily meet the criteria for a DSM-IV diagnosis of NPD. Overarching factors in the inventory include authority, superiority, exhibitionism, entitlement, vanity, exploitativeness, and self-sufficiency.

If you’re feeling up to it, you can take the test here.

As noted, this inventory is only used by clinicians. It’s frequently updated, and there’s no overwhelming consensus on its efficacy.

But as psychologists are increasingly discovering, many of these symptoms can be found in the general population. Moreover, these characteristics are not exhibited by all clinically diagnosed narcissists, nor do they manifest in precisely the same way. Indeed, like other psychological disorders, NPD may fall along a spectrum. Or it may manifest as several subtypes.

Which is precisely the thinking of Drew Westen and his colleagues who proposed three distinct subtypes back in 2008:

Grandiose/malignant narcissism

Characterized by anger, manipulativeness, thirst for power, exaggerated self importance.

Fragile narcissism

Characterized by grandiosity as a defensive function, feelings of inadequacy, anxiety, and loneliness.

High-functioning/exhibitionistic narcissism

Characterized by individuals being self-important, articulate, energetic, and outgoing.

It’s How You Were Raised — To A Degree

For the most part, NPS has baffled psychologists in terms of its causes. In the absence of neurological data, psychologists opted for psychodynamic explanations, especially the “blame your parents” angle. And indeed, there appears to be some empirical evidence to back this claim.

A recent study by R.S. Horton suggests that parental psychological control is linked to grandiose narcissism. But unlike previous studies, Horton found that parental coldness, incessant oversight, and over-valuation were not causal factors.

But clearly, there’s more going on the brain than just this.

Rooted in ‘Profound Fear’

On their own, psychoanalytic explanations are inadequate and unconvincing. This is where neuroscience can help. Last year, Elsa Ronningstam and Arielle Baskin-Sommers showed that NPD can be linked to fear and decision making processes. Indeed, feelings of fear have been frequently cited as a significant part of NPD pathology, and possibly even a motivating factor in narcissistic personalities.

Ronningstam and Baskin-Sommers say that the fear of dark and negative self-experiences, or even intolerable aspects of one’s identity, “can drive protective self-aggrandizement as well as destructive suicidal behavior enforced by overwhelming feelings of despair.” What’s more, certain events can trigger fears associated with earlier “narcissistic trauma.”

It’s possible, therefore, that NPD is a form of fear avoidance, especially of failure. It’s a “self-regulatory strategy” driven by specific motivations, including achievements, competitiveness, improvement of performance, and perfectionism.

Neurologically speaking, scientists have pinpointed the amygdala — the part of the brain that regulates processes like the detection of emotionally arousing and pertinent stimuli. Other regions, like the nucleus accumbens, hippocampus, and some prefrontal regions, form a neural network involved in the perception of threat, fear learning, and fear expression. Together, these areas act to produce an integrated fear response.

In addition, and relatedly, the hormone cortisol has been implicated in narcissism — at least in males. Cortisol is released in response to stress, which can be triggered by a fear response.

A Psychopathic Link

All of this sounds eerily familiar to another personality disorder: psychopathy. No doubt, many of the inventory items listed for NPD align closely with those on the psychopath diagnosis list, including symptoms of grandiosity, compromised empathic functioning, and callousness. It has been suggested that NPD and psychopathy are overlapping constructs. And in fact, some psychologists believe that narcissism might be the core of psychopathy. The role of fear as it relates to disinhibition is where the two overlap.

Ronningstam and Baskin-Sommers explain:

Similar to people with psychopathy, focused attention on goals, such as ambitions, competition, and aspirations, and even on risk-taking efforts, may, for some people with pathological narcissism and NPD, enable ignorance of fear and serve as a fear modulator. The narcissistic individual’s awareness is then directed away from potential triggers of feelings of fear and towards more securing or rewarding self-enhancing experiences.

On the other hand, given the psychoanalytic observations of profound fear in NPD, and the recognition of the thin-skinned and vulnerable narcissistic personality types, the question is whether some people with pathological narcissism and NPD indeed are hypersensitive or over-reactive to fear, or can have impaired capability to tolerate and/or process feelings of fear. It is also possible that when people with pathological narcissism or NPD have to face fear without the possibilities of engaging in avoiding, goal-directed, or self-enhancing strategies, the experience becomes overwhelming and consuming, forcing drastic decisions with seemingly immediate short-term gains.

Showing Empathy

As noted, narcissists are known for their apparent lack of empathy — a claim that was recently challenged by researchers at the University of Surrey and the University of Southampton. Their experiment on sub-clinical narcissists (not full-blown NPD), showed that extreme egoists can feel other people’s pain when they’re asked to imagine that they’re the ones suffering.

The finding shows that low empathy is not necessarily representative of an inability, an indication that intervention may be possible.

Other treatment options could include efforts to help narcissists focus and understanding their feelings of fear in terms of their self-functioning and self-directedness. But getting narcissists to accept this treatment — and to accept that they’re “deficient” somehow — may be easier said than done. That said, treatments should focus on having narcissists learn alternative strategies for dealing with their fears.

Tom Jacobs/Pacific Standard