Narcissism and Interpersonal Problems Among

ORIGINAL ARTICLE

Narcissism and Interpersonal Problems Among Psychiatric Outpatients What Is the Role of Defensive Style? Downloaded from http://journals.lww.com/jonmd by qY65rCLuId0yFW6LPgz/ORIUl86ZIxIqZjCR4L4XoBzNF4c2yLa/ZVG1FXwrfT3YkT2zKFlnRBtBtD7VoD4YEqbxOm5TwS1O9kkECraYQf35UGrqKoJjmMOah9QdZWRAsly/G3Y0AbM= on 08/30/2018

Michal Mielimaka, MD, PhD,* John S. Ogrodniczuk, PhD,† David Kealy, PhD,† Joanna Cheek, MD,† and Anthony S. Joyce, PhD‡

Abstract: A growing body of evidence points to significant interpersonal problems associated with narcissism in clinical samples. Less well understood are the mechanisms by which narcissism negatively impacts one’s interpersonal functioning. The present study investigated defensive style as a possible mediator of the relationship between narcissism and interpersonal problems. A sample of 53 adult psychiatric outpatients completed measures of narcissism, defensive style, interpersonal problems, and current symptom distress. Mediation analysis was conducted, controlling for current symptom distress, using 95% bootstrapped confidence intervals to examine the indirect effect of narcissism on interpersonal problems via defensive style. Narcissism was significantly associated with immature and neurotic defensive styles. Although narcissism was not directly related to interpersonal problems, a significant indirect effect was observed for narcissism on interpersonal problems via neurotic defensive style. This finding suggests that narcissism contributes to the use of neurotic defenses, which in turn influence one’s interpersonal functioning. Key Words: Narcissism, defensive style, interpersonal problems, defense mechanisms (J Nerv Ment Dis 2018;206: 711–715)

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arcissism is commonly associated with interpersonal problems. The DSM-4 with DSM-IVand DSM-5 describe narcissistic personality disorder as a pervasive, rigid pattern of interpersonal functioning characterized by admiration-seeking, entitlement, lack of empathy, exploitation or envy of others, and grandiose attitudes (American Psychiatric Association, 1994, 2013). These characteristics consequently predispose individuals to difficulties in social functioning and immense suffering from social isolation and loneliness (Campbell and Baumeister, 2006; Kealy et al., 2015). Contemporary psychoanalytic understanding of pathological narcissism implies that severe interpersonal problems are an expected consequence of narcissistic pathology (Auerbach, 1993), and due to the complexity of the hypothesized etiology of narcissistic pathology, its interpersonal manifestation is expected to be diverse. Indeed, available research indicates that higher levels of narcissistic traits are associated with problematic interpersonal functioning such as domineering, vindictive, and intrusive behaviors, which eventually hinder the establishment of satisfactory, long-term relationships (Cheek et al., 2018; Dickinson and Pincus, 2003; Kealy and Ogrodniczuk, 2011; Ogrodniczuk et al., 2009). Narcissistic features amplify the link between perceptions of others’ dominance and one’s own quarrelsomeness, with negative affect acting as a mediator

*Department of Psychotherapy, Jagiellonian University Medical College, Krakow, Poland; †Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada; and ‡Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada. Send reprint requests to Michal Mielimaka, MD, PhD, Department of Psychotherapy Jagiellonian University Medical College, ul. Lenartowicza 14, Krakow, 31–138, Poland. E‐mail: [email protected]. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/18/20609–0711 DOI: 10.1097/NMD.0000000000000871

(Wright et al. 2017). Moreover, narcissistic traits have been found to be associated with social introversion (Rathvon and Holmstrom, 1996), as well as decreased straightforwardness and altruism, and lower levels of compliance (Miller et al., 2017), further reflecting significant interpersonal difficulties. Many clinical observations reveal severe difficulties in psychotherapy with narcissistic individuals that emanate from the challenging interpersonal behaviors of such patients (Caligor et al., 2015; Ellison et al., 2013; Kealy and Ogrodniczuk, 2011). Although mounting evidence supports the association between narcissism and interpersonal problems, research attention directed at finding more specific explanations is limited, leaving the mechanisms underlying these associations to remain unknown. Among the myriad factors that may play a role in the connection between narcissism and interpersonal problems is the defensive style of the individual. Defensive styles are understood as the propensity to use certain types of defense mechanisms in particular circumstances (Soldz et al., 1995). Defense mechanisms may be regarded as automatic psychological responses that individuals use in response to anxiety, internal or external stress, and conflict (American Psychiatric Association, 1994; Perry, 2014; Porcerelli et al., 2016). Generally, defense mechanisms that are considered more mature allow an individual to effectively distance threatening feelings without distorting reality. Mature defense mechanisms (e.g., anticipation, humor, sublimation) are associated with adaptive functioning and favorable aspects of personality including extraversion, openness, and agreeableness (Granieri et al., 2017). Neurotic defense mechanisms (e.g., idealization, reaction formation) are associated with anxiety and mood disorders (Calati et al., 2010; Joyce et al., 2013). Immature defense mechanisms (acting out, projection, splitting) are associated with personality and affective disorders (Calati et al., 2010; Perry et al., 2013; Zanarini et al., 2013) and are highly related to early maladaptive schemas (Walburg and Chiaramello, 2015). Results from the longitudinal study performed by Strandholm and colleagues show that neurotic and immature defense styles in adolescence are associated with personality disorders in adulthood (Strandholm et al., 2016). Although defense mechanisms are conceptualized as intrapsychic processes, most of them (e.g., projection, displacement, splitting, projective identification) impact interpersonal functioning. The hypothesized relationship between immature/neurotic defenses and interpersonal problems has been researched and gained considerable support (Bullitt and Farber, 2002; Joyce et al., 2013; McNulty, 2008). Greater use of healthy, adaptive, mature defense mechanisms by pregnant mothers and less frequent use of maladaptive defenses (including denial, projection, rationalization) predict greater attachment security, better socialemotional competence, and fewer behavioral problems in their toddlers (Porcerelli et al., 2016). Mature defense mechanisms applied by divorced parents foster increased participation of the parents in the lives of their children. Interestingly, greater utilization of mature defenses even by only one parent is associated with an increase in the cooperation and involvement of both parents (Cohen and Finzi-Dottan, 2012). Even in difficult, often conflict-provoking interpersonal situations, the application of mature defenses fosters more beneficial interpersonal functioning. In

The Journal of Nervous and Mental Disease • Volume 206, Number 9, September 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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The Journal of Nervous and Mental Disease • Volume 206, Number 9, September 2018

Mielimaka et al.

contrast, neurotic adults have been found to be less happy in relationships because of how they construe their interpersonal experiences, making more negative attributions for their partners’ behaviors (McNulty, 2008). Ciocca et al. (2017) have observed that immature defenses are associated with paranoid ideation, which negatively affects interpersonal functioning. Joyce et al. (2013) reported that application of mature defense style has been inversely associated with being socially avoidant and with personality disorder pathology. Use of neurotic defenses demonstrated relationships with interpersonal problems associated with being exploitable or intrusive. Immature defense style was significantly correlated with interpersonal problems in the areas of being vindictive, cold, socially avoidant, and overly nurturant. Both immature and neurotic defenses were correlated with personality disorder pathology and with poorer outcome of dynamically oriented partial hospital group treatment (Joyce et al., 2013). Defense styles are significantly associated with maladaptive personality domains, implying that they may comprise core components of personality disorder (Granieri et al., 2017). Specifically, Granieri and colleagues found that immature defenses (including acting out, autistic fantasy, isolation, dissociation, projection, and splitting) predicted higher scores on maladaptive personality domains. In particular, isolation, dissociation, autistic fantasy, and acting out predicted scores in the antagonism personality domain, which includes grandiosity among other personality facets (Granieri et al., 2017; Krueger et al., 2012). Narcissistic personality disorder has been found to be associated with immature and neurotic defensive styles including the use of omnipotence, devaluation, autistic fantasy, projection, intellectualization, and splitting of self-image and of other image (Perry et al., 2013; Perry and Perry, 2004). Cramer identified the specific defense mechanism of immature projection as being strongly related to narcissistic personality traits (Cramer, 1999). Moreover, a study by Zeigler-Hill and colleagues (2008) revealed associations between immature defense styles and self-esteem instability—a fundamental aspect of pathological narcissism. Conversely, high levels of mature defenses were associated with less self-esteem instability (Zeigler-Hill et al., 2008). The theoretical concepts are, to some extent, overlapping— interpersonal pathology has been considered a core problem of trait narcissism, and limited diversity and low elasticity in using defenses has also been associated with trait narcissism. However, interpersonal pathology has been identified in many psychiatric disorders, and also in disorders not associated with trait narcissism. Defensive styles vary not only across different psychiatric disorders, but also within patients with similar diagnosis; thus the repertoire of applied defenses may be substantially differentiated. For the present study, exploration aimed at disclosing differences among seemingly overlapping concepts was undertaken with the goal to be able to better understand the complexity of the interactions between narcissism, defense styles, and interpersonal problems. Collectively, the findings from these various studies point to the possibility that the influence of narcissism on interpersonal problems among psychiatric outpatients may at least partially operate via the defensive style of individuals. To our knowledge, no study has explored this possibility. The present study examines the role of defensive style as a possible mediator of the relationship between narcissism and interpersonal problems. We hypothesize that interpersonal problems of narcissistic patients may be considerably influenced by the repertoire of applied defenses. Immature and neurotic defenses may contribute to greater interpersonal pathology of narcissistic patients, whereas mature defenses may be associated with an increase in interpersonal satisfaction.

METHODS Participants Fifty-three consecutively admitted patients to the Day Treatment Program (DTP) of the University of Alberta Hospital in Edmonton, Canada, served as participants in this study. The DTP is known to 712

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community referral sources as an outpatient service that treats patients with personality disorders or maladaptive personality disorder traits. The primary inclusion criteria for the program were the presence of a DSM-IV personality disorder or significant personality dysfunction that does not fully meet criteria for any particular DSM-IV Axis II disorder, and a minimum age of 18 years. Exclusion criteria included active psychosis, organic mental disorder, acute suicidality, active substance abuse in need of primary attention, and involvement with another mental health agency. Ethics approval for the study was obtained from the university health research ethics board. After complete description of the study to the subjects, written informed consent was obtained. Participants were 34 women and 19 men; the median age was 41 years, with a range from 19 to 66 years. Forty percent were married or cohabiting, 24% were separated or divorced, and 36% had never been married. Thirty percent of participants were employed either full-time (21%) or part-time (9%). Fifty-eight percent had completed some form of postsecondary education. Most participants (93%) reported previous psychiatric treatment, whereas 30% had previously been hospitalized for psychiatric reasons.

Measures Narcissism was assessed with the Wisconsin Personality Inventory (WISPI-IV; Smith et al., 2003), a 214-item self-report questionnaire organized into 11 scales, with each scale corresponding to one of the DSM-IV personality disorders. The WISPI-IV items and scales were derived from the DSM personality disorder symptom criteria. However, they are different from other self-report measures of personality disorder (e.g., Structured Clinical Interview for DSM-IV Personality Disorder [SCID-II]) because they have been translated and reformulated according to an interpersonal theory of personality (Benjamin, 1996). Validation studies demonstrate excellent internal consistency and test-retest reliability (Smith et al., 2003) and good convergent and discriminant validity with the SCID-II (Barber and Morse, 1994; Klein et al., 1993). The 40-item Defense Style Questionnaire (DSQ-40; Andrews et al., 1993; Bond et al., 1989) is a self-report instrument assessing derivatives of commonly used defense mechanisms. The DSQ-40 provides subscale scores for three clusters of defenses: immature defenses (e.g., projection, passive aggression, acting out), neurotic defenses (e.g., pseudo-altruism, idealization, and reaction formation), and mature defenses (e.g., suppression, anticipation, and humor). Andrews et al. report moderate to high internal consistency (Cronbach’s alpha ranging from 0.58 to 0.80) and high test-retest reliability (ranging from 0.75 to 0.85) for the three subscales. Interpersonal problems were assessed with the Inventory of Interpersonal Problems (IIP-64; Horowtiz et al., 1988). The IIP-64 is a self-report instrument designed to assess problems in interpersonal interactions that either are reflected by difficulties in executing particular behaviors (“It is hard for me to…”), or difficulties in exercising restraint (“I do… too much”). The instrument is based upon interpersonal theories of behavior (Kiesler, 1996; Leary, 1957; Sullivan, 1953). The scale consists of 64 items that are rated on a 5-point scale and provides a total score that reflects overall distress associated with interpersonal problems. The IIP-64 is a widely used instrument and has strong psychometric properties (Horowitz et al., 2000). General symptom distress was assessed with the symptom distress subscale of the Outcome Questionnaire (OQ-45; Lambert et al., 1996), a 45-item self-report measure. The items address common symptoms and problems (mostly depressive and anxiety based) that occur across the most frequently occurring psychiatric disorders. The OQ-45 is frequently used and possesses good psychometric properties (Ellsworth et al., 2006).

Procedures Analyses were performed using SPSS version 24, including the PROCESS macro (Hayes, 2017). Zero-order correlations were computed © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.


to examine simple relationships between all variables in the study. Regression with mediation analysis was employed using the total score from the IIP-64 as the dependent variable (Y), the WISPI-IV narcissism score as the independent variable (X), and defensive style as the mediator (M); current symptom distress was included in the model as a control variable. The three defensive style scores (mature, neurotic, immature) were entered as simultaneous mediators in the model. Bootstrapped 95% confidence intervals (CIs) were estimated, using 10,000 resamples. The statistical significance of an indirect effect of pathological narcissism— via defensive style—on interpersonal problems would thus be indicated by the CI not including zero.

RESULTS As shown in Table 1, pathological narcissism, neurotic and immature defensive styles, interpersonal problems, and current symptom distress were significantly associated with one another in expected directions at the bivariate level, with correlation coefficients ranging from 0.34 for pathological narcissism and neurotic defensive style to 0.58 for pathological narcissism and immature defensive style. All significant direct correlations reflected moderate associations between measured variables. Mature defensive style was not significantly related to any other variables. Results of regression analyses (Table 2), controlling for current symptoms, indicated that pathological narcissism was significantly related to immature and neurotic defensive styles. Although a significant direct, bivariate relationship between narcissism and interpersonal problems was observed, inclusion of other variables (i.e., defensive styles) into the model considerably reduced the effect of narcissism on interpersonal problems (Table 2). Instead, a significant indirect effect was observed for pathological narcissism on interpersonal problems through neurotic defensive style only, suggesting that use of neurotic defensive strategies shaped by narcissistic dysfunction contributes to interpersonal problems. To provide a more nuanced perspective of specific interpersonal problems that may underlie our findings, we conducted a post hoc exploration of the mediation model using each of the eight IIP-64 subscales. These post hoc analyses revealed that the mediation model was significant for three of the subscales: nonassertiveness, exploitable, and intrusiveness.

DISCUSSION Consistent with clinical observations and existing research evidence, we found that pathological narcissism was related to immature and neurotic defensive styles. However, only neurotic defensive style emerged as a significant mediating variable in the relation between narcissism and interpersonal problems, endorsing its role in shaping the perception of interpersonal functioning among patients with high levels of pathological narcissism. Neurotic defenses, such as idealizations, may be triggered in narcissistic patients when confronted with interpersonal disappointments (e.g., encounters that fail to buttress the patient’s TABLE 1. Zero-Order Correlations Between Pathological Narcissism, Defensive Styles, and Current Symptom Distress 1 1. Pathological narcissism 2. Mature defensive style 3. Neurotic defensive style 4. Immature defensive style 5. Interpersonal problems 6. Current symptom distress

2

0.02 0.34* 0.01 0.58** −0.21 0.41** −0.20 0.10 −0.23

3

4

0.32* 0.48** 0.48** 0.21 0.52**

*p < 0.05. **p < 0.001.

5

0.55**

Narcissism and Defensive Styles

fragile sense of self ) and may point to aspects of narcissistic vulnerability (Dickinson and Pincus, 2003). It is interesting that immature defensive style failed to emerge as a mediator of the effect of narcissism on interpersonal problems, despite its strong association with narcissism. Perhaps using neurotic defensive styles, in comparison with immature defenses, allows for more awareness into the relational consequences of one’s behavior, possibly speaking to the hypersensitive facet of narcissism. Applying primarily immature defenses may limit the ability to gain insight and understand how others are affected by one’s own actions and attitudes, therefore distorting the perception of interpersonal problems (enabling one to be oblivious to such problems). Another possible explanation is based on the nature of immature defenses (Cramer, 2008, 2015); many of them (e.g., splitting, projective identification) hinder the ability to incorporate seemingly contradictory qualities into one stable image. The perception of interpersonal problems by an individual using immature defenses will more frequently be either exaggerated or depreciated, and the direction and strength of the distortion––dependent on many variables––may be difficult to predict. It should also be taken into consideration that the narcissistic patient may employ neurotic-level defenses in a more rigid fashion, that is, without any kind of flexibility or openness to modification. Using these defenses in each and every situation of interpersonal dispute or conflict increases the likelihood of interpersonal problems. The results of our research underline the importance of detailed analysis of interpersonal functioning of narcissistic patients. Significant associations among trait narcissism, interpersonal problems, and immature/ neurotic defense styles reveal complex mechanisms, in which the impact of perceived interpersonal problems of narcissistic patients is mediated by neurotic defense mechanisms. In our view, this underlines the distinctive aspects of the theoretical constructs of trait narcissism, defense mechanisms, and interpersonal problems. The complex nature of association of trait narcissism and functioning in interpersonal situations has also been detailed by Wright and colleagues (2017). Quarrelsomeness and dominance were associated with perceiving others as challenging, dominating or taking control. These associations were mediated by negative affect. These results correspond with the three subscales of interpersonal problems found to be significant in our mediation model: nonassertiveness, exploitable, and intrusiveness. Further research on various pathways of the relationship between trait narcissism and functioning in interpersonal situations in light of the discussed results thus seems justified. Moreover, characteristics of defensive style patterns in interpersonal situations of narcissistic patients should be regarded in the context of complex mental representations of self and other; thus building on a comprehensive model of the mind to develop further understanding of the diversity and dynamics of personality functioning of narcissistic patients (Blatt and Auerbach, 2000). The content of the representations will shape interpersonal functioning with additional influence of defensive styles. Richness and elasticity in application of defense styles may be seen, to some extent, as independent from mental representations of self and other, although the growth and development of ego (including the capability to use various defenses) should be influenced by the content of mental representations of self and other, and vice versa. Applying an adaptive model in future research of associations between psychopathology and personality functioning is recommended. An obvious and important limitation of our study is the relatively small sample of patients and overrepresentation of females in the study group. Generalizability of our findings should be regarded with adequate caution. Another potential limitation is the fact that almost all people in the sample (93%) were patients already in treatment/previously treated, which may have influenced their conscious views on interpersonal functioning and utilization of defenses. Moreover, the sample consisted only of people willing to go to treatment, which also may be a source of bias, as many patients with strong narcissistic traits may not feel the need to seek therapy. Finally, as the WISPI-IV was designed to be

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Mielimaka et al.

TABLE 2. Results of Regression Analyses Examining the Indirect Effect of Narcissism on Interpersonal Problems, Through Defensive Style as Mediator F

R2

1.01

0.04

DV: Mature Defensive Style Narcissism Symptom distress (control)

F

R2

3.67

0.14

DV: Neurotic Defensive Style Narcissism Symptom distress (control)

F

R2

26.62

0.55

DV: Immature Defensive Style Narcissism Symptom distress (control)

F

R2

9.06

0.52

DV: Interpersonal Problems Mature defensive style Neurotic defensive style Immature defensive style Narcissism Symptom distress (control)

b

SE

t

p

0.57 −0.15

1.45 0.11

0.39 −1.39