​Pathological narcissism is believed to arise from early traumatic empathic failures by caregivers who were experienced as confusing, unpredictable, and/or driven by hidden agendas. Inconsistent and untrustworthy caregiving creates instability and insecurity in a child’s sense of self, resulting in fragile self-esteem heavily dependent on external affirmation. To manage their deep-seated need for admiration and intense yearnings for approval, the child learns to present a false self, masking true feelings and vulnerabilities unrecognized or unacceptable to caregivers, instilling instead a fear of exposure and consequent criticism and rejection. The affective experience of not being seen or known by caregivers during critical developmental periods alters a child's sense of self, affecting their self-worth and agency and impairing their ability to form secure attachments, as they divest themselves of meaningful emotional investment in others.

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These difficulties in regulating self-esteem can result in pathological narcissism, a disorder characterized by dynamically oscillating states of grandiosity and vulnerability. Narcissistic vulnerability manifests as a brittle sense of self, emotional instability, and impaired empathic functioning, coupled with excruciating feelings of shame, self-doubt, rage, envy, and loneliness. In response to these vulnerabilities, individuals employ maladaptive, self-enhancing strategies to bolster a view of themselves as exceptional and deflect recognition of their vulnerabilities. Expressions of narcissistic grandiosity often impede meaningful relationships, limiting the capacity for mutuality and reciprocity.

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The impact of untreated pathological narcissism on partners, family members, and children is significant. Through the projection of their intolerable feelings of inadequacy onto others, narcissists perpetuate cycles of intergenerational trauma and cause devastating social effects. This has also led to greater awareness of the need for mental health support and treatment for those in relationships with, and directly impacted by, individuals with pathological narcissism. People with pathological narcissism generally seek help only after an acute personal or professional crisis or loss (e.g., excessive interpersonal conflict with family and/or employers, increasing dissatisfaction with their life, etc.). The mainstay of treatment is individual psychotherapy -- specifically, psychoanalytic therapy -- which is typically long-term.  

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