Asian Journal of Psychiatry 54 (2020) 102117

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Asian Journal of Psychiatry

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The fear of what goes up must come down: A case report of vulnerable narcissism T

ARTICLE INFO ABSTRACT

Keywords: Pathological narcissism or narcissistic personality disorder is commonly characterized by an exaggerated sense
Covert of self-importance, condescending attitude, need for excessive admiration, diminished empathy and exploita-
Vulnerable tiveness. In contrast to these overt attributes, there is a different presentation of pathological narcissism which is
Pathological narcissism underrecognized, as one’s preoccupation with hypervigilant, self-effacement and proneness to shame in the
Narcissistic personality
context of covert grandiose fantasies. This report illustrates a patient who had this subtype of vulnerable nar-
Paraphilia
cissism, and how his defence had been activated to preserve own self agency during a session with the doctor by
revealing his paraphilic fantasy.

1. Introduction academically. However, they never complimented his achievements,

Pathological narcissism or narcissistic personality disorder is a
highly complex and pleomorphic entity which is characterized by an
exaggerated sense of self-importance, condescending attitude, need for
excessive admiration, diminished empathy towards others and ex-
ploitativeness, thus resulting in significant interpersonal difficulties in
their career, social and family-life trajectories (Gabbard and Crisp,
2018).
Conceptually, there are two distinctively different presentations of
individuals with pathological narcissism, ranging from overt and
grandiose to covert and vulnerable (Dickinson and Pincus, 2003;
Gabbard, 1989). Historically, this typology is influenced by the classic
psychoanalytic writings of Otto Kernberg and Heinz Kohut. However,
the features of covert-vulnerable subtype are underrepresented diag-
nostically in the Diagnostic and Statistical Manual of Mental Disorders,
fifth edition (DSM-5; American Psychiatric Association, 2013).
Although these two subtypes may occur in pure form, many patients
present with a mixture of both. Often than not, they oscillate between
these two states of mind over time, depending on the vicissitudes of
interpersonal encounters (Gore and Widiger, 2016). Relatively, corre-
lates and underpinnings of the covert-vulnerable narcissism can be well
hidden. Patients nondisclosure and their narcissistic defensive stand
protects the vulnerable internal world from being accessed.
2. Case report
Mr. F was a final year law student in his early 20′s who came for
treatment after his 5-year relationship with his girlfriend ended. He
presented with depression, suicidal thought, transient auditory hallu-
cinations which were derogatory, as they would laughingly comment
that he was useless, and nobody would care for him. On further history,
he reported chronic feelings of emptiness and worthlessness since the
age of 13. They were cemented by a long-standing struggle with low
self-esteem.
Growing up in a family who emphasized the importance of success,
his parents had high expectation and pressured him to perform
but instead, liked to compare him with others, thus left him feeling
invalidated. He too viewed his parent as emotionally detached, dis-
missive, lack of empathy and they would exert physical punishment
without listening to his explanation. Despite these frustrations, he ad-
mired his parents’ commitment to work and how they excelled at their
jobs. He wished to be viewed as a good son and to be just successful like
them.
Throughout his growing years, he recalled memories of being bul-
lied by his peers who made fun of his physical attributes. He also found
himself difficult to fit into any group of friends, feeling rejected, lonely
and anxious to the extent of self-effacing. While he chose to be alone,
howbeit he was viewed by others as arrogant. Although he attempted to
seek companionship from female friends when they came forward with
problems, he quickly felt overwhelmed and perceived that others were
only nice to him for their personal gain but unwilling to offer help re-
ciprocally.
Despite these negative feelings, he excelled in his academics and
had actively participated in a lot of extracurricular activities such as
debate, public speaking and sports. He furtively recalled moments when
he was the only one chosen from his class to be part of the school debate
team. This made him feel anxious, but at the same time excited. He
would constantly remind himself not to be overjoyed as the saying
“what goes up must come down”. Mr. F continued to score top grades until
high school when his confidence was steeply crumbled with a sense of
failure for unable to surpass his peers with higher marks.
Mr. F had strong sense of self-entitlement since young. When his
younger brother was born, he felt a loss of his “special position” within
the family as he lost his parents’ attention as he could no longer choose
his television programme, the dining choices or his favourite toys.
Resentfully, he described his younger brother as rebellious, but his
parents would still pamper his brother incessantly. Later, he too felt
deprioritize and subsequently criticized various people in his life in-
cluding the previous therapist for not being helpful, as they were all
deemed lack of understanding to his conditions.
Mr. F had multiple attempts of self-harm which began at 9 years old.
These include twisting, cutting his hands and until the extend of asking

https://doi.org/10.1016/j.ajp.2020.102117
Received 16 April 2020; Accepted 17 April 2020
1876-2018/ © 2020 Elsevier B.V. All rights reserved.

others to suffocate or induce pain towards him. These sensations would
give a sense of relief which he described as feeling at peace. In other
times, the self-inflicted injury also served to convince others that he was
unwell. For instance, he resorted to hammer his knee in order to con-
vince others that he was unfit to play in a sport competition. Lately, he
contemplated jumping off high building, but was stopped by the
thought of his act would traumatise his friends. Although he reported of
having fleeting thoughts to kill himself, but worried of dying un-
discovered.
In relationship, he was attracted to ladies who had strong person-
ality, independent and mature. He would feel suffocated if they were
too clingy but silently wished for their unequivocal attention and sa-
crifice. He constantly needed to be listened to about his problems in life,
to the extent of longing desperately for a response. When a termination
was initiated by the other half, he would severely devastated and
subsequently resorted to self-harms.
During psychotherapy intake assessment, especially sexual history
taking, Mr. F checked on the acceptance of the therapist. It was fol-
lowed by a careful attention to the therapist’s reaction about his habit
of watching necrophiliac pornography. This specific pornography had
become the source for his sexual arousal and orgasm in compared to the
other forms of pornography. Throughout the session, he focused on the
therapist’s silent manifestations of discomfort. Intermittently, he even
paused and checked if the therapist would be alright to continue with a
smirk.
3. Discussion
This case highlights the distinctive features of covert-vulnerable
narcissism which is characterized by hypersensitivity to rejection, self-
effacement and profound sense of shame. We attempt to dissect the
patient’s presenting history along with these features.
Firstly, individuals with covert-vulnerable narcissism are hypervi-
gilant and hypersensitive to rejection and criticism. In the context of
interpersonal relationships, they often actively search for any evidence
of critical reaction from others and feel slighted at every turn. They
have propensity to identify potential criticism from every corner and
constantly keep themselves on guard against any insults to their frag-
mented self-esteem (Gabbard and Crisp, 2018). Consequently, they
present with a heightened sense of self-consciousness about how they
are coming across to others. For instance, the intense fear of being re-
jected by his peers had led Mr. F to resort to extreme measure of in-
juring himself to prove that he was unwell to participate in a sport
competition instead of showing his unreadiness.
Secondly, they come across as shy, withdrawn & inhibited to the
point of self-effacement. They dislike being in the limelight if it opens to
opportunity for others to glimpse into their vulnerability. This also
explains the difficulties in forming therapeutic relationship, as it feels
being stripped naked and exposing them, therefore evoking a painful
sense of humiliation. Many defences will be activated and utilised to
shield themselves from this potential harm.
We would like to highlight these by illustrating on the patient’s
unconscious manoeuvre to preserve his sense of agency and self-esteem
in front of the doctor who was trying to explore and unravel his vul-
nerable self-experience of inadequacy, fearfulness, and sensitivity. The
situation during the exploration of his paraphiliac fantasy might have
diverted the centre of vulnerability to the doctor instead, who was
seemingly affected by the gory nature of its content. The smirk re-
presented a triumph over the therapist that he had a better level of
mastery in this area where others cannot stomach.
Lastly, people with covert-vulnerable narcissism have an inner
world that filled with profound sense of shame in the context of covert
⁎
Corresponding author.
Asian Journal of Psychiatry 54 (2020) 102117
grandiose fantasies (Cain et al., 2008; Bateman, 1998; Gabbard, 1989).
Deeply, they have unconscious wish to exhibit themselves in a grand-
iose manner which could be uncovered by an insight-oriented therapy
process. The central of the shame is an ingrained self-perception of ir-
reparably defective or inadequacy. Therefore, they are often envious of
other’s success and constantly compare themselves with the standard of
perfection they pursue but never achieve. Mr. F’s desire to be seen as a
successful person illustrates this sense of covert grandiose fantasy, but
eventually envied others who had outperformed him.
In conclusion, with this complex representation of narcissistic per-
sonality disorder, one should not only be well aware of the overt-
grandiose subtype but to also give equal attention to the covert-vul-
nerable narcissism that is currently underrepresented by our current
diagnostic criteria.
Ethical statement
We have obtained an informed consent from the patient. The pa-
tient’s details have also been kept anonymize. The report also meets the
ethical guidelines and meets the legal requirements in the country in
which data were collected - Malaysia.
Financial support and sponsorship
Nil.
Consent for publication
Written informed consent was obtained from the patient.
Declaration of Competing Interest
There are no conflicts of interest.
Acknowledgement
The authors are grateful to the patient for his consent to the writing
of this case report. The authors are also thankful to the Director General
of Health Malaysia for his permission to publish this article.
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Seng Choi Chong*, Jin Kiat Ang, Hazleana Hashim
Department of Psychiatry, Faculty of Medicine and Health Sciences,
Universiti Putra Malaysia, Serdang, Selangor 43400, Malaysia
E-mail addresses: sengchoi@upm.edu.my (S.C. Chong),
jinkiat@upm.edu.my (J.K. Ang),
hazleanahashim1904@gmail.com (H. Hashim).