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Simone Hoermann, Ph.D.Simone Hoermann, Ph.D.
A blog about the personality disorders (borderline, narcissistic, etc.) with a focus on research and therapy

Unhealthy Narcissism

Simone Hoermann, Ph.D. Updated: Feb 4th 2010

yellow narcissus mirrored on blue surfaceIn a blog a while ago, I wrote about people with Narcissistic Personality Disorder and touched on the distinction between healthy and pathological narcissism.  In short, healthy narcissism has to do with a healthy sense of self worth and self-esteem, a healthy sense that you deserve to have and achieve good things and success in life, and that you deserve have positive relationships and to be treated well.  Healthy narcissism has to do with a realistic sense of one’s own worth and a realistic sense of one’s own abilities, rights, and obligations.  I’d like to go a little bit more into writing about unhealthy – or pathological- narcissism.  You can find a detailed description of the diagnostic criteria for Narcissistic Personality Disorder listed in the Diagnostic and Statistical Manual of Mental Disorders here.

According to Elsa Ronningstam, author of the book “Identifying and Understanding the Narcissistic Personality”, the prevalence of Narcissistic Personality Disorder in the general population is considered fairly low to moderate, with different studies reporting between 0.4% to 5.3% of the general population meeting criteria for Narcissistic Personality Disorder.  Interestingly, the incidence of Narcissistic Personality Disorders has been found to be somewhat higher in people with higher education and in special professions.

Ronningstam describes different types of unhealthy narcissism as characterized by three features: 1.) dysregulated self-esteem, 2.) dysregulated affect, 3.) interpersonal difficulties.

In terms of dysregulated sense of self-esteem, someone with pathological narcissism is exquisitely sensitive and fragile.  Criticism can feel devastating to them, and they have a very hard time dealing with failure or defeat.  Often, they protect their fragile sense of self-worth by covering it up with presenting as though they feel special and unique, or have special abilities, and with fantasies of perfect, special, or powerful.

            When it comes to their affect, meaning, what they feel emotionally, people with unhealthy narcissism can get very dysregulated as well. They can feel their emotions very strongly, and frequently are plagued by feelings of intense anger or rage, and painfully intense feelings of shame, or envy. 

            Interpersonal relationships of someone with unhealthy narcissism tend to be characterized by behaviors that serve the preservation or augmentation of their self esteem. This means they can come across as arrogant, haughty, and entitled.  Other are frequently used as a means to bolster their self-worth, so they like to associate with people who admire them, or who themselves are special, accomplished, or famous.  This can also take on the opposite form, though, in that some people with unhealthy narcissism are particularly shy and are so protective of their self-esteem and so afraid of humiliation and shame, that they avoid the slightest chance of being criticized by avoiding attention from others, and so they avoid any risk of failure by not pursuing relationships or professional goals.

            Unhealthy narcissism is viewed to appear on a continuum and can come in a very wide range from very mild to extremely severe.  Some people only have a few features of narcissism that can get in their way and can cause trouble for them.

In contrast, on the other extreme end of the spectrum is psychopathy.  Elsa Ronningstam, as well as another expert on narcissism, Otto Kernberg, view psychopathy as the most severe, most extreme, and most malignant form of narcissism.  Psychopaths have most severe difficulties in all these three areas above.  They protect their self-esteem through immoral or violent behavior, are characterized by intense rage and envy, tend to be irritable, and to exploit others.  They engage in immoral, violent, or criminal behavior, are revengeful and sadistic, and lack any sense of guilt or remorse.  Psychopathy overlaps with the Antisocial Personality Disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders.


Simone Hoermann, Ph.D.Simone Hoermann, Ph.D., is a Psychologist in private practice in New York City. She specializes in providing psychotherapy for Personality Disorders, Anxiety, and Depression. She is a faculty member of Columbia University, and facilitates psychotherapy and skills training groups at the Columbia East 60th Street Day Treatment Program.

Reader Comments
Discuss this issue below or in our forums.

Struggled with one - Ken - Jun 13th 2012

I worked for one, sadly, not knowing anything about this illness.  It became very clear later as I discovered what the illness entails.  I would say it was all there in him, just a matter of breaking it down in detail, once you know more about how this illness is so pervasive and all-encompassing.  

The complexity of what they are, hides them from you being able to figure them out and understand them.  It takes a longtime to accumulate the abuse points that add up to your realizing this individual is not the great \\

Excellent Article - Cathy - Feb 5th 2010

I have read a lot on narcissism and thought this article was excellent.  It puts it in a nutshell so someone desperately (if you have a narcissist in your life, you will be desperate) can get a good idea of what they might be dealing with and then go on from there.

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