Narcissistic Personality Disorder at the Neurotic Functioning Level: An Insight into Overt and Covert

Article written in collaboration with @taniacatasso_psicologa

Introduction

Narcissistic personality disorder (NPD) is among the most debated psychopathological conditions in contemporary clinical literature, suspended between a still imperfect categorical definition (American Psychiatric Association, 2013) and growing empirical evidence highlighting its phenomenological heterogeneity (Miller et al., 2017; Pincus & Lukowitsky, 2010). Understanding DNP requires combining at least three axes of analysis: the structural level of personality organization (neurotic, borderline, psychotic), the expressive phenotype (grandiose/overt vs. vulnerable/covert), and the theoretical frameworks that explain its evolutionary origin. This in-depth study aims to articulate these three plans in a systematic way.

Kernberg's structural model: a necessary premise

Kernberg (1984) proposes to evaluate personality pathology not so much based on manifest symptoms, but on the underlying structural organization, defined by three parameters:

1. Identity integration: the ability to maintain a stable, coherent, three-dimensional representation of oneself and others, integrating positive and negative aspects (Kernberg & Caligor, 2005).

2. Type of defense mechanisms: At the neurotic level, defenses centered on removal prevail (inhibition, intellectualization, reactive formation, nullification), while at more severe levels, defenses based on splitting predominate (idealization/devaluation, projective identification, denial) (Kernberg, 1984).

3. Reality check: the ability to distinguish self from non-self, internal world from external world, maintaining critical judgment even under stress.

At the neurotic level, all three parameters are preserved: this is why, in so-called "high-functioning" narcissism, the subject can maintain prominent professional roles, stable relationships at least on the surface, and a capacity for introspection that makes him, clinically, more accessible to treatment than borderline or psychotic organizations of narcissism (Caligor et al., 2015; Stern et al., 2017).

It is important to note, as Caligor et al. (2015) point out, that neurotic functioning in narcissism does not equate to the absence of suffering: suffering simply shifts from the relational/behavioral plane (agitation, instability) to the intrapsychic plane (perfectionism, corrosive self-criticism, chronic feeling of insufficiency masked by external success).

Overt and covert: from the clinic to empirical research

The origins of the construct

The distinction between "manifest" and "hidden" narcissism does not arise in the DSM, but in the psychoanalytic clinic. Kohut (1971) and Kernberg (1975) already described narcissistic patients with opposite symptomatic presentations while sharing the same underlying structure. The term covert narcissism is however systematized empirically by Wink (1991), who, through factor analysis of the California Psychological Inventory, identifies two independent dimensions of narcissism: Vulnerability-Sensitivity and Grandiosity-Exhibitionism, demonstrating that both correlate with clinically significant narcissistic traits but are behaviorally almost opposite.

The model of Pincus and colleagues

Pincus and Lukowitsky (2010) contributed decisively to integrating this distinction into a unitary model of pathological narcissism, distinguishing it from "normal" or adaptive narcissism. According to the authors, the pathological core common to overt and covert is made up of:

• Pathological grandiosity: fantasies of unlimited success, perceived entitlement (entitlement), interpersonal exploitation, which in the overt form expresses itself openly and in the covert form remains confined to the internal ghostly world, accompanied by shame for one's need for admiration.

• Narcissistic vulnerability: intense emotional reactivity to perceived threats to self-esteem, experiences of emptiness, anger, shame — present in both variants, but more clinically visible in the covert.

Cain, Pincus and Ansell (2008) highlight how this oscillation between grandiosity and vulnerability is not necessarily stable over time: the same individual can move between the two poles as a function of the relational context and the level of perceived threat to self-esteem — a fact that has led some authors to prefer the term "floating" or "oscillating" narcissism to a rigid typological dichotomy (Ronningstam, 2009).

Measuring instruments

An important contribution to the empirical validation of the distinction has come from the development of specific psychometric tools, in particular the Pathological Narcissism Inventory (PNI; Pincus et al., 2009), which separately measures grandiosity and narcissistic vulnerability, overcoming the limitations of the Narcissistic Personality Inventory (NPI; Raskin & Terry, 1988), which is predominantly calibrated to the grandiose/overt component and therefore not very sensitive to the covert variant.

Theoretical frameworks compared

Kernberg: The Pathological Grand Self

For Kernberg (1975, 1984) pathological narcissism is based on a specific defensive structure: the pathological grandiose Self, the result of the fusion between ideal representation of the self, representation of the ideal object and real (albeit selected) aspects of the self. This fusion allows the subject to deny dependence on the real object — experienced as an intolerable source of envy — by projecting onto the outside the devalued aspects of himself. The price paid is the impossibility of authentic identity integration: behind the apparent cohesion of the grandiose Self lies a masked fragmentation, which resurfaces in moments of failure or confrontation with real limits.

Kohut: the evolutionary deficit

Kohut (1971, 1977) proposes a radically different perspective, not conflictual but deficient. Pathological narcissism arises from a failure of "Self-object" functions (selfobject functions) — mirroring (mirroring) and idealization — by primary caregivers. A child whose expressions of infantile grandeur are not adequately reflected, or whose idealizing figures prove systematically disappointing, fails to transform such needs into stable psychic structures (a cohesive Self capable of self-regulation of self-esteem) through the process of "transmuting internalization." It therefore remains structurally dependent on external confirmations — a deficit, not a conflict to be removed.

This theoretical difference (conflict vs. deficit) has relevant technical implications: where Kernberg favors the systematic interpretation of aggression and envy in transference, Kohut favors sustained empathy and understanding of unmet Self-object needs (Kohut, 1977).

Contemporary perspectives: towards an integrated model

Ronningstam (2005, 2009) e Caligor et al. (2015) propongono modelli integrativi che collocano overt e covert non come categorie separate ma come espressioni fenotipiche di un continuum strutturale, influenzato da fattori temperamentali, di attaccamento e ambientali. Russ, Shedler, Bradley e Westen (2008), attraverso metodologia Q-sort su un ampio campione clinico, identificano empiricamente tre sottotipi di narcisismo — grandioso/malevolo, fragile e ad alto funzionamento/esibizionistico — offrendo un'evidenza empirica indipendente alla validità clinica di distinzioni più fini rispetto alla semplice dicotomia overt/covert.

Development and risk factors

Although a single etiological theory is lacking, the literature converges on some recurring risk factors: parenting styles characterized by excessive idealization or, conversely, emotional criticism and coldness (Otway & Vignoles, 2006); insecure attachment, particularly avoidant or disorganized (Smolewska & Dion, 2005); family environments in which affection is conditioned on performance. Interestingly, opposing parenting patterns —hyperidealization vs. devaluation— can both lead to narcissistic outcomes, more oriented towards the overt or covert pole, respectively, confirming the multifactorial complexity of the disorder.

Clinical implications and treatment

Therapeutic and countertransference alliance

Therapeutic and countertransference alliance

Recognition of the prevalent phenotype significantly guides clinical management. With overt patients, the therapist is typically exposed to countertransferential experiences of devaluation, irritation, or defensive submission, generated by the patient's tendency to use the clinician as a public or as an object to be controlled (Kernberg, 1984; Ronningstam, 2009). With covert patients, countertransference more often takes on the traits of overprotection, silent frustration, or difficulty comparing a grandiosity that presents itself disguised as fragility (Ogrodniczuk & Kealy, 2013).

Evidence-based treatment models

At the level of neurotic functioning, the literature particularly indicates:

• Stern, & Kernberg, 2022), who systematically works on the analysis of the pathological grandiose Self through the interpretation of transference.

• Expressive-supportive psychodynamic approaches, calibrated to the patient's capacity for mentalization and insight (Caligor et al., 2015).

• Mentalization-Based Treatment (MBT) adapted to pathological narcissism, which emphasizes reconstructing the ability to mentalize affective states related to shame and envy (Drozek & Unruh, 2020).

Unlike borderline levels, where containment and stabilization work prevails, at the neurotic level therapeutic work can focus more directly on the processing of intrapsychic conflicts (rivalry, envy, fear of failure) thanks to the patient's greater reflective capacity (Stern et al., 2017).

Construct limitations and criticalities

It should be noted that the discriminatory validity between overt and covert narcissism remains a matter of debate. Miller et al. (2017), in a critical review, underline how some authors consider narcissistic vulnerability closer, from the point of view of personality structure, to general internalizing and neurotic traits (e.g. negative affectivity) rather than to a "hidden" form of the same grandiose construct. This suggests caution in the clinical use of dichotomy as a rigid category, in favor of a dimensional and contextual reading, consistent with the alternative model approach for personality disorders proposed in the DSM-5, Section III (American Psychiatric Association, 2013), and with the PDM-2 (Lingiardi & McWilliams, 2017), which integrate dimensions of structural severity and functioning profiles.

Conclusions

Analysis of narcissistic personality disorder at the neurotic functioning level reveals a more nuanced and clinically complex pathology than the popular stereotype suggests. Integrated identity, mature defenses, and preserved reality testing coexist with a structurally fragile regulation of self-esteem, expressed along a continuum between manifest grandiosity (overt) and hidden vulnerability (covert), often oscillating within the same individual. The theoretical frameworks of Kernberg and Kohut, although starting from different premises — intrapsychic conflict versus evolutionary deficit — converge in recognizing the centrality of the regulation of self-esteem as a pathogenic nucleus. A clinical approach informed by this complexity, capable of recognizing the prevalent phenotype without rigidifying into clear categories, today represents the most effective standard for the diagnosis and treatment of pathological narcissism.

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