Health, 2020, 12, 1279-1298

https://www.scirp.org/journal/health
ISSN Online: 1949-5005
ISSN Print: 1949-4998

The Dark Reflection of Sadism

within the Brilliance of the
Narcissistic Persona

Xanya Sofra1,2

City University, London, UK

1

New School for Social Research, New York, USA

2

How to cite this paper: Sofra, X. (2020) Abstract

The Dark Reflection of Sadism within the
Brilliance of the Narcissistic Persona. Health, This double blind randomized clinical trial with 84 participants, revealed that
12, 1279-1298. mental patients diagnosed with narcissism, and narcissistic celebrities mirror
https://doi.org/10.4236/health.2020.129092
each other’s paranoid, obsessive and histrionic symptomatology, grandiosity,
Received: August 17, 2020
manipulative charm, and inner emptiness. Elite narcissists manifested insidi-
Accepted: September 26, 2020 ous sadism in the absence of depressive affect, while the narcissistic patients
Published: September 29, 2020 were differentiated by their depressive and masochistic symptomatology. Elite
narcissists demonstrated advanced empathic skills, contradicting past litera-
Copyright © 2020 by author(s) and
Scientific Research Publishing Inc. ture. However, their empathic advantage appeared void of compassion, merely
This work is licensed under the Creative employed as a self-serving tactic to exploit, intimidate and subordinate. Both
Commons Attribution International experimental narcissistic groups evidenced more prevalent psychopathology,
License (CC BY 4.0).
yet, higher achievement, efficacy and ambition than their reciprocal control
http://creativecommons.org/licenses/by/4.0/
groups, confirming the narcissists’ finesse in concealing psychopathology
Open Access
under the brilliance of their pseudo-superiority. The main danger is the affin-
ity between masochism and sadism, bonding low and high functioning nar-
cissistic counterparts to endlessly feed from each-others’ pathology, forming
dysfunctional interpersonal relationships, cults or disintegrating societies.
This sadomasochistic dependency also reflects several countries’ authoritar-
ian trends, where narcissistic constituents’ unyielding loyalty elevates idolized
leaders to power, preluding the establishment of toxic tyrannical govern-
ments.

Keywords
Narcissism, Sadism, Masochism, Obsessive Symptoms, Histrionic Symptoms,
Paranoia Symptoms, Personality Disorders, Thematic Apperception Test,
Narcissistic Personality Inventory, Anaclitic Depression, Introspective
Depression, Empathy, Dominance

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X. Sofra

1. Introduction
This clinical trial is important in view of the current political climate with grow-
ing narcissistic tendencies, observed in several countries, where constituents
elect their leaders to fit an idealized version of themselves. Enchanted by the
outward flamboyance of a magnetic, yet covertly defective personality, people
expose themselves to the profiteering, and malfeasance of those they promote to
power. The supreme selected ones, or in Kohut’s terms the “mirror hungry”
narcissists, shine the celestial glow of grandiosity upon their ardent supporters,
elucidated by Kohut as the “ideal-hungry” followers [1] [2] [3]. The devotees are
driven by the erroneous belief that the leaders’ supremacy has transformational
powers to reform them into glamor replicas, actualizing their narcissistic ambi-
tion for superiority and perfection. Losing this alliance depletes hope, submerg-
ing them into a dreamless emptiness. This interdependent relationship is beyond
adoration; it entangles leaders and devotees into an unbreakable, indispensable
attachment, that Seiden delineated as the “narcissistic counterpart” interconnec-
tion [4].
The criteria for narcissism listed by the diagnostic and statistical manual of
mental disorders (DSM) have remained the same over the years: arrogance, gran-
diosity, entitlement, envy, a relentless pursuit of luxury, wealth, and endless love,
eroded by a lack of empathy and a disingenuous negative form of attachment,
driven by exploitation [5].
Narcissism has been generally illustrated as a dimension that encompasses
both the normal and the pathological spectrum. Kernberg defines normal nar-
cissism as the eroticized or libidinal investment in the ego identity, deemed as a
comprehensive whole of dynamically integrated “all good” and “all bad” percep-
tions of self and others. This consolidated, realistic self/others’ appraisal is a
precondition for empathy. In contrast, pathological narcissism reflects mutually
dissociated, contradictory ego states that alternate without ever being unified,
resulting in chronic feelings of emptiness, delusional grandiosity, and a marked
incapacity to perceive oneself and others as enriched multidimensional entities
with the wholeness and depth of a human being; hence leading to deficient em-
pathic skills, impaired interpersonal relationships, and distorted egocentric judg-
ment [6]. The main characteristic of pathological narcissism is an unrealistic
grandiose self that has emerged out of consistently devaluing others to protect
against their own pervasive sense of inadequacy. Unlike normal narcissism,
where gratification is derived by both external and internal sources, the patho-
logical narcissist depends exclusively on others’ admiration to nourish the flawed
self’s omnipotence. In the absence of an external supply of applause and praise,
these individuals sink into the desolate blankness of intolerable anonymity.
Kernberg defines the narcissistic character structure as aggressive, sadistic, ex-
ploitive and envious, in contrast to the relatively more benign profile drawn by
Kohut, who envisions narcissistic patients as deficient, a sketchy caricature rather
than a whole person, hypersensitive to criticism, and driven by the attachment of

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idealization or the repulsion of devaluation [7] [8]. According to Kernberg, sa-

dism is inherent in the psychodynamics of malignant narcissism that serves as
the bridge connecting antisocial and narcissistic character dimensions. The ma-
lignant narcissist’s antisocial behaviour is inflamed by ego-syntonic aggression
and sadism. Lashing out their aggression confirms their superiority and feeds
their grandiosity. This seemingly purposeless venting of aggression is con-
trasted by the antisocial personality’s repertoire, that reflects predominantly
parasitic and manipulative behaviours targeting material self-gain [9] [10].
Kernberg’s analysis of narcissism is contrasted, enriched and complemented
by several other clinicians, including: a) The DSM team [11]. b) Ronningstam
and Gunderson’s narcissistic configuration [12] [13] [14]. c) Akhtar and Thom-
son’s conceptualization [15].
The original DSM task force on Axis II grouped personality syndromes into
three broad symptomatologic clusters: 1) the odd or eccentric cluster (paranoid,
schizoid, schizotypal); 2) the dramatic, emotional or erratic cluster (histrionic,
narcissistic, antisocial and borderline); 3) the anxious and fearful cluster (avoidant,
dependent, compulsive, passive-aggressive) [16] [17]. According to this scheme,
narcissistic individuals were bound to share some features with histrionic, anti-
social and borderline individuals, by virtue of belonging to the same group.
However, this arrangement predicts no relationship between paranoid or obses-
sive features and narcissism.
Ronningstam and Gunderson differentiated narcissism by its sense of superi-
ority and uniqueness, boastful and pretentious behaviour, grandiose fantasies,
arrogant, haughty, self-centred and self-referential behaviour, need for attention
and admiration, and self-esteem that is utterly dependent on high achievement.
Unlike the antisocial personality that generally disregards the values and rules in
society, the narcissistic personality commits crimes only as a result of uncon-
trollable rage, or to avoid defeat [18].
Akhtar and Thomson have proposed six areas of psychological functioning,
which are divided into overt and covert aspects, implying that certain clinical
features are more conspicuous than others, as a consequence of the splitting de-
fence: the necessary segregation within the self, raising a border between ideal-
ized “good” and devaluated “bad”, to protect the individual from their destruc-
tive conflict that can irreparably damage the psychological apparatus. Narcissis-
tic personality disorder is defined as overtly grandiose, exploitive, often success-
ful, featured as CEOs of major corporations, or top government officials, im-
pressively knowledgeable but with a “headline intelligence” that lacks substance.
Covertly, narcissists are doubt-ridden, deeply envious of others, chronically bored,
corruptible, and unable to love [19]. The notion of shallow exhibitionistic knowl-
edge or “headline intelligence” came from Olden [20]. The narcissist’s communica-
tion style is tainted by ambition, the insatiable need for admiration and the in-
flexible conviction that they are gifted with a natural talent for everything. Their
speech is composed by the most dramatic, dazzling information bits, a mosaic of

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superficiality, void of details or a profound understanding of concepts. Their

comprehension is characterized by impenetrable rigidity, like an impassable
solid wall of concrete, that bounces off anything inconsistent with its already
crystallized conclusions, rejecting opposite arguments, or classifying incoming
information as hostile, disrespectful and offensive. They value loyalty at the ex-
pense of science and information. They often practice logic-defying, unidimen-
sional, faulty judgment, displaying an allergy to criticism, and unforgiving rage
against opponents. Overall, narcissists usually ruminate in a circular manner
manoeuvring language to regulate self-esteem or accomplish a goal; thus, a lis-
tener may sense a gap between ideas and beliefs, that often appears quixotic or
irrational [21].
The narcissist’s unrestrained drive for extravagance and success is best de-
scribed by Fenichel’s phenomenon of the “Don Juan of Achievement” defined by
a compulsion for accomplishment to ultimately gain approval [22]; and Tarta-
koff’s description of individuals with a “Nobel Prize Complex”, who are charac-
terized by a burning ambition to attain great wealth and awards [23].
Akhtar has further clarified narcissism by juxtaposing it against other person-
ality disorders. Both narcissistic and obsessional personalities are driven by
achievement, perfectionism and the need for control. However, obsessives are
compliant with authority, while narcissists reject anyone who imposes power
upon them. The obsessive is modest, manifesting rigid morality; the narcissist is
haughty, contemptuous, with a self-serving, corruptible value system [24]. On
the surface, narcissism may appear similar to the hysterical personality; however,
the narcissist’s exhibitionism and seductiveness have an exploitive and cold qual-
ity, in contract to the warmth, and playfulness of the hysterical persona. The
hysteric’s capacity for empathy, concern, and love for others is impaired in nar-
cissism. Both paranoid and narcissistic disorders are characterized by a facade of
aloof grandiosity, devaluation of others, difficulty in accepting criticism, defec-
tive empathy, chronic envy and a sense of entitlement. However, the paranoid
lacks the attention-seeking charm and seductiveness of the narcissist. Paranoids
are uncomfortable around others and lack a sense of humour. The acute, highly
vigilant, yet, biased cognition of the paranoid is juxtaposed against the narcis-
sist’s disregard for details and resistance to learning, since inherent in learning is
the assumption of ignorance and inferiority [25].
Wilson’s conceptualization of narcissism involves a lower and higher level of ad-
aptation [26]. Narcissistic patients reject incoming information to avoid self-esteem
deflation. They understand others through symbiotic merger and emotional
contagion. Upper class successful narcissists employ empathy to exploit others
and advance their goals disregarding, or unable to fathom the richness and com-
plexity of human existence. Their empathic skills are often distorted by envy,
antagonism, contempt and the projection of their own negative self-image on
those they regard as subordinates. Both upper and lower level narcissists display
paranoid symptoms. However, the narcissistic patient’s paranoia is driven by

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what Auckincloss termed the “impossibility of indifference”, where being ig-

nored is experienced as worse than being prosecuted [27]. Successful narcissists,
on the other hand, adopt a paranoid cognitive style, constantly scanning for ad-
versaries, or hidden dangers, to secure and safeguard their influential positions.
Although depression is inherent in both levels of narcissism, the mental patients
exhibit anaclitic melancholy, permeated by fears of abandonment, helplessness,
and emptiness. In contrast, powerful egocentric individuals respond to failure
by harsh self-criticism, aggression turned inwards, and introjective depression,
infused by sadistic impulses. The successful narcissists’ sadism is infiltrated by
disdainful domination of their subjects, solely for self-aggrandizement, treating
others as trophies, or useless objects to be discarded [28]. Their interdependent
counterparts, the low-level, narcissistic masochists, develop an addictive obses-
sion with their aggressor, who is perceived as the sacred need-gratifier. They in-
troject the admired persons’ sins and impairment to protect their idols from de-
valuation and rejection that would unequivocally submerge them into anaclitic
abandonment and despair [29].

2. Subjects
Eight-four Caucasian subjects were randomly selected out of one hundred and
twenty subjects who qualified to participate in the study. They were divided into
two experimental and two control groups: 1) Experimental group of twenty-five
poorly adapted narcissistic patients. 2) Experimental group of twenty-five well
adapted narcissistic individuals. 3) Control group of seventeen patients with pa-
thologies other than narcissism. 4) Control group of seventeen high achievers
without narcissistic features. The groups were classified on the basis of the
three screening instruments, NPI, PDQ and Gunderson’s interview for Narcis-
sism. The diagnoses and other psychological testing available in the charts of
the two patients’ groups were also taken into consideration. The patient popu-
lation was found in two different mental health day treatment centres, located
in two different parts of the world, that approved the research in accordance
with their ethical standards, and principles for medical research involving hu-
man subjects. The remaining subjects were randomly selected from country
clubs and other VIP private organizations that consented to participate in the
study.
The inclusion and exclusion criteria for the patient population were as fol-
lows: 1) The narcissistic patient group consisted of patients diagnosed on Axis II
with a Narcissistic Personality Disorder. 2) The non-narcissistic patient group
consisted of patients diagnosed on Axis II with a personality disorder not other-
wise specified with either borderline, dependent, avoidant or passive aggressive
features. 3) Only the following Axis I diagnoses of the DSM were included in the
study: Adjustment disorders, Panic disorder with or without Agoraphobia, and
Generalized Anxiety Disorder. 4) Participating patients did not have a history of
more than two hospitalizations, or a history of rehabilitation in mental health

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day programs for more than two years. The reason for this requirement was to
exclude very regressed patients. 5) All psychiatric patients included in the study
were unemployed and received public assistance. 6) All patients ranged from 26
to 55 years of age. The mean age of the patient subjects was 35.6. 7) None of the
patients suffered from an organic mental disorder, including brain tumours,
strokes or brain damage as a result of an accident, neurological disorder, or se-
vere learning disability as was indicated by the chart notes. 8) None of the pa-
tients had a history of drug or alcohol intoxication or dependency, as indicated
by the admission note and history in the chart. 9) None of the patients suffered
from any major physical illness as indicated by their medical exam in the chart.
10) Any patient with an IQ less than 85, as noted in the chart, was not included
in the study. The mean IQ of the subjects was 105.4. 11) Patients with the fol-
lowing diagnoses on Axis I were excluded: Developmental disorders, Dysthymia,
Major Depression and Bipolar disorders, Psychoactive Substance Abuse disor-
ders, Schizophrenia, Delusional/Paranoid disorders, Obsessive-Compulsive dis-
order, Somatoform disorders and Dissociative disorders.
The participants of the two normal samples were randomly selected and were
later classified as narcissists and non-narcissists on the basis of the screening
psychological test battery administered that included the NPI, PDQ and Gun-
derson’ Interview for Narcissism. The inclusion and exclusion criteria were: 1)
Subjects ranged from 34 to 59 years of age. The mean age of the subjects was
51.3. 2) Subjects had a yearly income that exceeded $150,000 USD. 3) Subjects
had at least a Masters’ degree. 4) Subjects were celebrities or had successful ca-
reers as directors or CEOs of large corporations. 5) No history of mental illness.
6) No major medical disorders. 7) No history of drug or alcohol abuse. 8) Never
being in psychotherapy.
The patients diagnosed with a narcissistic personality disorder were compared
against elite successful individual identified as narcissists by the NPI, the PDQ
and Gunderson’s interview for Narcissism. They were also compared against the
non-narcissistic patients. The elite narcissists were compared against their non-
narcissistic colleagues and the narcissistic patients. The two experimental and
control groups’ comparisons are illustrated in Table 1.

3. Instruments
3.1. The Narcissistic Personality Inventory—NPI
This instrument was used for screening the presence of a narcissistic personality
disorder in both patients who already had an established diagnosis and high
functioning individuals with no history of mental illness. The NPI consists of 54
dyadic items in a forced choice format. The subject chooses the statement he/she
identifies with the most. The internal and external validity of the NPI has been
tested on both clinical and non-clinical samples with verified construct, conver-
gent, and discriminant validity. The NPI is not a unitary conceptual assembly,
but rather consists of four moderately correlated factors: Leadership/Authority,

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Table 1. Experimental and control groups. Total number of subjects N = 84.

Experimental Group Compared to: Control Group

Educated Elite Narcissists in high Educated Elite Non-Narcissists in high
professional positions (N = 25) professional positions (N = 17)
Fulfilled the criteria for Narcissism on the NPI, Did not fulfil the criteria for Narcissism on the
PDQ and Gunderson’s Interview for NPI, PDQ and Gunderson’s Interview for
Narcissism. High Socioeconomic status Narcissism. High Socioeconomic status.
Income $150,000 plus. Income $150,000 plus.
34 - 59 years old 34 - 59 years old

Compared to

Experimental Group Narcissistic Patients Compared to: Control Group

(N = 25) Non-Narcissistic Patients (N = 17)
Outpatients in Psychiatric Facility. Outpatients in Psychiatric Facility. Diagnosed
Diagnosed with a Narcissistic Personality with Personality Disorders NOS. Low
Disorder. Low Socioeconomic Status. Socioeconomic Status.
Unemployed. 26 - 55 years old Unemployed. 26 - 55 years old

Self-Absorption/Self-Admiration, Superiority/Arrogance, and Explo-itativene-

ss/Entitlement, a scale that is highly correlated with pathological narcissism
[30]-[36].

3.2. Gunderson’s Interview for Narcissism

This semi-structured interview was also used to screen for narcissism. It identi-
fies pathological narcissism on the basis of 33 statements. These statements ex-
plore levels of grandiosity, interpersonal relationships, responses to adversity and
criticism, affect and mood states, social and moral adaptation [37] [38].

3.3. The Personality Diagnostic Questionnaire—PDQ

The PDQ was the third screening instrument used in this study to identify pa-
thology. It is a self-report instrument that consists of 163 true-false items that
generally correspond one-to-one with specific DSM personality disorders crite-
ria. The efficiency of the PDQ was established by a series of studies that demon-
strated that the measure is both reliable and valid [39] [40] [41].

3.4. The Depressive Experiences Questionnaire—DEQ

This instrument was included to distinguish between two levels of depression: 1)
anaclitic/dependency; and 2) introjective/guilt-ridden/self-criticism. The DEQ is
a 66-item questionnaire, in which subjects rate each statement on a point scale
that ranges from “strongly disagree” to “strongly agree”. The 66 items of the DEQ
were selected by several judges from a list of 150 statements, because they repre-
sented a relatively broad range of phenomenological experiences associated with
depression. It is based on three major factors: 1) Dependency expressed in feeling of
loneliness, helplessness and abandonment. 2) Self-criticism, reflecting guilt, empti-
ness and failure to meet expectations and standards. 3) Efficacy involving issues re-

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lated to adaptability, self-confidence and self-esteem [42] [43] [44] [45] [46].

3.5. Epigenetic Assessment Rating Scale—EARS

This measure was important to outline the differential characteristics of the two
levels of narcissistic personality organization, represented by the two experi-
mental groups: the narcissistic patients and the high-functioning successful nar-
cissists. The EARS scoring system was applied by testing the subjects’ verbal and
nonverbal responses to two Thematic Apperception Test (TAT) stories, low arousal
card 1, and high arousal card 13MF. The EARS’ developmental continuum was
first formulated by Gedo [47] [48] [49]. The EARS was constructed to account
for five modes of personality organization: 1) “Mode I” coincides with Kern-
berg’s psychotic level, permeated by the fear of self-obliteration. Information is
encoded in non-verbal action-oriented forms. Self and other are merged symbi-
otically. 2) “Mode II” reflects a borderline personality constellation, driven by
splitting, aggression, anxiety over abandonment, and a biased perception of oth-
ers as a projection of the self. 3) “Mode Ill” is embellished by egocentricity,
self-enhancement, and self-gratification. Others serve as targets of exploitation,
evaluated in terms of their utility, social position, or level or success; and are eas-
ily discarded when their serviceability is depleted. 4) “Mode IV” coincides with
Kernberg’s neurotic level. It is characterized by enriched verbal communication,
a capacity for empathy, and emotional independence, with sporadic regressions
into self-doubt and conflicted states. 5) “Mode V” is the highest level of psycho-
logical integrity, morality and self-control, characterized by sublimation and
creativity [50] [51] [52] [53].

3.6. Structured Interview for DSM Personality—SIDP

The SIDP is a structured interview, which consists of 16 topical sections cor-
responding to different personality criteria. It was included to assess, obses-
sive-compulsive, paranoid and histrionic personality symptoms and styles [54] [55].

3.7. Structured Interview for DSM Personality—Revised SIDP-R

The SIDP-R is a revision of the SIDP with 17 topical sections, that have added
the diagnostic descriptions of the sadistic and masochistic personality disorders.
[56] [57].

4. Procedure
This clinical trial was conducted over a period of eighteen months and all sub-
jects were followed for the duration of this study. The purpose of the study was
diagnostic. No treatment outcomes were examined since none of the Elite Nar-
cissists were in psychotherapy. Subjects that consented to be in the study were
told that they were participating in personality research designed to distinguish
between different character styles. To avoid evaluation apprehension, which
would be a threat to the construct validity of the design, subjects were reassured

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that there were no right or wrong answers. They were told: “Any response is
useful in constructing your personality portrait, like a precious work of art, that
is always exclusive and valuable, irrespective of its contents. Therefore, there is
no reason to lie or try to appear under a positive light, because that would
merely distort the secret individualistic merit of your true nature and make you
appear mundane and commonplace”. Subjects were instructed to answer all
questions according to the way they are most of the time, rather than the way
they would like to be, or thought they should be, in order to construct an accu-
rate profile that was unique and specific to them.
All subjects were screened with the NPI, the PDQ, and Gunderson’s interview
for narcissism. Copies of the charts from all mental health participants were
examined in detail before determining the subjects’ categorization into the pa-
tients’ experimental and control groups. Ten days after the first interview, all
subjects were given the DEQ, the EARS, the SIDP and SIDP-R. The EARS was
administered via a low arousal (card1) and a high arousal (card 13MF) of the
Thematic Apperception Test (TAT). Testing instructions were standardized for
all subjects: “I will show you two pictures. Please tell me a story that has a begin-
ning, a middle and an end. Please tell me about the people’s actions, thoughts
and feelings. Tell me what happened before, what is happening now, what will
happen after, and what will be the final outcome in the future”. Subjects re-
sponses were video-taped and transcribed. The recordings of the different sub-
jects’ stories were transferred to a new video tape in random sequence, to ensure
that the sequence of subjects’ recordings on the tape did not consist of subjects
belonging to the same group for the purpose of independent rating. Tapes and
transcripts of subjects’ responses on EARS were given to two independent
judges with extensive training in the EARS system. Inter-rater reliability be-
tween the two judges was determined by Pearson’s R reliability coefficient
which was R = 0.846 (p < 0.00001) for card 1 and R = 0.765 (p < 0.00001) for
card 13MF.
In order to control for various validity threats the following steps were taken:
1) To establish diagnostic purity on the PDQ, only subjects that endorsed 96% of
the narcissistic disorder items, and less than two items in the diagnostic criteria
of any other personality disorder were included in the high narcissism groups. 2)
Subjects qualified to be in the high narcissism groups only if they were at least
1.5 standard deviation above the mean of the NPI. Subjects who qualified to be
in the non-narcissistic groups were at least 1.5 standard deviation below the
mean of the NPI. 3) Gunderson’s interview was administered by an expert who
was trained by Dr Ronningstam with a high reliability coefficient of R = 0.926 (p
< 0.00001). Dr Ronningstam was part of the research team that developed Gun-
derson’s interview in 1990. Following administration, the subjects’ written re-
sponses were collected, placed in files with numbers after the names were de-
leted, and were subsequently scored blindly. Only subjects that obtained a scaled
score of at least 9 in Gunderson’s interview that signifies pathological narcissism

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were included in the narcissistic group. Non-narcissistic subjects who were se-
lected to be in the study obtained a scaled score of less than 4 in Gunderson’s
interview. 4) In order to control for acquiescence effects, subjects were asked to
give detailed responses and examples in Gunderson’s Interview rather than an-
swering “yes” or “no”. 5) The sample size was sufficiently large so that the power
of the statistical tests was Power = 0.80, which is considered to be the optimal
power to detect whether there is a significant difference between two experi-
mental and two control groups. The power of a test is defined as the probability
of rejecting the null hypothesis when it is, in fact, false. Symbolically, power is
defined as the probability of the type II error subtracted from unity (power =
1-probability of type II error). A power of 0.80 is optimal because it brings a
balance between type I and type II errors. When the power is too high (power >
0.90) a study may find significance where there is none, i.e. make a type I error.
If the power is too low (power < 0.60) a study may fail to find significance and
accept the null hypothesis, when the null hypothesis is actually false (type II er-
ror). 6) The SIDP and SIQP-R were also administered by experts who had over-
all agreement ratings of R = 0.85 (p < 0.00001) for the SIDP and R = 0.86 (p <
0.00001) for the SIDP-R with the developers of these instruments. Further analy-
sis yielded a Kappa of 0.71, at p < 0.001 level. 7) The differentiation between
symptoms and styles in the SIDP and SIDP-R was done on the basis of the fol-
lowing dimensions: a) activity versus passivity; b) cognitive distortions of reality;
c) impairment of overall social functioning. 8) The DEQ was scored by a com-
puter program.

5. Results
The data on character traits, depression, and efficacy were analysed by MANOVAS
that compared the four groups along the dimensions of obsessiveness; hys-
teria, paranoia, sadism, masochism of the SIDP and the SIDP-R, as well as the
dependency, self-criticism and efficacy factors of the DEQ. The data on the
Empathic Knowledge of others (EK) dimension of the EARS were analysed by
the Mann-Whitney U test, the Wilcoxon Rank Sum W test and the Chi Square
test.
The four groups were differentiated by the SIDP and SIDP-R, along the dimen-
sions of obsessiveness, paranoia and hysteria, masochism and sadism. The sig-
nificance values for all groups are given in Table 2. A comparison between the
two experimental groups representing narcissistic patients and elite narcissists
revealed the following: 1) Narcissistic patients/group 1 were found to be signifi-
cantly higher in terms of both histrionic and paranoid symptoms and style (his-
trionic symptoms/style: F: 13.02; p < 0.001; paranoid symptoms/style: F: 32.76; p
< 0.001). 2) The narcissistic patients also demonstrated significantly higher maso-
chism (F: 133.98; p < 0.001) than the elite narcissists. 3) Elite narcissists scored
significantly higher on sadism (F: 7.56; p < 0.009) when compared to the narcis-
sistic patients.

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Table 2. Results of SIDP and SIDP-R.

Obsessive Obsessive Histrionic Histrionic Paranoid Paranoid

Groups Sadism Masochism
Style Symptoms Style Symptoms Style Symptoms

Narcissitic Patients
No
(Group 1) F: 133.98; No difference F: 13.02; F: 13.02; F: 32.76; F: 32.76;
difference
vs Successful Narcissists p < 0.001 NS p < 0.00 p < 0.00 p < 0.001 p < 0.001
NS
(Group 2)
Experimental
Elite/Successful
Narcissists (Group 2) F: 7.56;
vs Narcissistic Patients p < 0.009
(Group 1)

Narcissistic Patients
1. Control High vs
(Group 1) F:12.29; F: 12.29 F: 5.54; Substantially F: 9.05; Substantially F: 9.50; F: 9.56;
Low Narcissim
vs Other Patients p < 0.001 p < 0.001 p < 0.024 equivalent p < 0.005 equivalent p < 0.01 p < 0.004
Patients
(Group 3)
Elite/Successful
2. Control High vs Narcissists F: 3.07;
F: 111.51; Substantially F: 8.87 F: 26.71; F: 5.23; F: 68.92; F:5.53;
Low Narcissim (Group 2) p < 0.088
p < 0.001 equivalent p < 0.005 p < 0.000 p < 0.028 p < 0.001 p < 0.024
Successful Adults vs Other Successful NS
Adults (Group 4)

Narcissistic patients’ experimental group showed higher masochism than both the experimental group of successful narcissistic adults and more sadism and
masochism than the patient control group. They also manifested more histrionic and paranoid symptoms than the experimental group of successful narcis-
sists and more obsessive, histrionic and paranoid traits, as well as paranoid symptomatology when compared to the control group of patients. The
elite/successful narcissists manifested greater sadism than both the experimental group of patients and the control group of successful adults. They also
evidenced greater obsessive, histrionic and paranoid traits, as well as paranoid symptomatology when compared to other successful adults. Abbreviations:
SIDP: Structured Interview for DSM Personality. NS: Result is statistically non-significant.

Table 2 also depicts narcissistic patients/group 1 being compared to non-

narcissistic patients/group 3 on the SIDP and the SIDP-R, along the dimensions
of obsessiveness, paranoia, hysteria, masochism and sadism with the following
results: 1) Group 1 was significantly higher than group 3 in obsessive style (F:
5.54; p < 0.024) and histrionic style (F: 9.05; p < 0.005). 2) Group 1 was also sig-
nificantly higher than group 3 in both paranoid symptoms (F: 9.56; p < 0.004)
and style (F: 9.50; p < 0.01). 3) Group 1 was much higher than group 3 in both
sadism (F: 12.29; p < 0.001), and masochism (F: 12.29 p < 0.001).
High functioning affluent narcissists/group 2 were compared to non-narcissistic
high achievers/group 4 unveiling the following findings (Table 2): 1) Group 2
was significantly higher than group 4 in obsessive symptoms (F: 26.71; p <
0.000) and obsessive style (F: 8.87 p < 0.005); 2) paranoid symptoms (F: 5.53; p <
0.024) and style (F: 68.92; p < 0.001); 3) and both histrionic symptoms (F: 3.07; p <
0.088) and histrionic style (F: 5.23; p < 0.028). However, it should be noted that
the histrionic symptoms value did not reach statistical significance. 4) Elite nar-
cissists, group 2, manifested significantly more sadism than group 4 (F: 111.51; p
< 0.001).
The four groups were compared on the Efficacy, Dependency, and Self-criticism
factors of the DEQ (Table 3). Narcissistic patients/group 1 scored higher than
group 2 on the Dependency factor of the DEQ (F: 20.23; p < 0.001), as well as the
Self-criticism factor (F: 28.60; p < 0.001). Elite Narcissists/Group 2 scored higher

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than group 1 on the Efficacy factor (F: 7.31; p < 0.01).

Table 3 reveals that the narcissistic patients/group 1 scored significantly higher
than non-narcissistic patients/group 3 on both the Self-criticism factor (F: 2.82; p <
0.034), and the Efficacy factor (F: 5.39; p < 0.026) but not the Dependency/anaclitic
factor where the two groups were substantially equivalent.
Table 3 also indicates that successful Narcissists/group 2 scored higher than
group 4 on the Efficacy factor (F: 8.43; p < 0.006).
The two experimental narcissistic groups were compared on the Empathic
Knowledge of Others (EK) dimension of the EARS (Table 3). Results were ana-
lysed by the Mann-Whitney U test and the Wilcoxon Rank Sum W test. Successful
narcissists/group 2 scored higher than group 1 on card 1 of the TAT which repre-
sented the low arousal condition (Mann-Whitney U: 165.0; p < 0.001; Wilcoxon
Rank Sum W: 686; p < 0.001). Although successful narcissists also scored slightly
higher than their successful colleagues of group 4, on the EK of card 1, the result
did not reach statistical significance (Table 3). Under high arousal conditions
(card 13MF) the elite narcissists scored higher than the narcissistic patients, how-
ever, the result was statistically insignificant. Under high arousal conditions elite
narcissists had a capacity for empathy that was equivalent to their non-narcissistic

Table 3. Results of DEQ and EARS.

DEQ EARS Capacity

DEQ DEQ Self EARS Capacity for
Efficacy/Capacity for Empathy
Dependency/Anaclitic Criticism/Introjective Empathy Low
to adjust and High arousal
Depression Depression arousal condition
succeed condition

Narcissitic Patients
(group 1) High Dependency High Self Criticism
vs Successful Narcissists F: 20.23; p < 0.001 F: 28.60; p < 0.001
(group 2)

Experimental High empathy

Successful Narcissists 1. Mann-Whitney
Relatively
(group 2) High Efficacy U: 165.0; p < 0.001
Higher
vs Narcissitic Patients F: 7.31; p < 0.01 2. Wilcoxon Rank
NS
(group 1) Sum W: 686; p <
0.001

Narcissisic Patients
1. Control High Appeared more
(group 1) High Self Criticism High Efficacy Substantially Substantially
vs Low Narcissim independent than
vs Other Patients F:2.82; p < 0.034 F: 5.39; p < 0.026 equivalent equivalent
Patients other patients NS
(group 3)

Successful Narcissists
2. Control High
(group 2) Substantially Substantially High Efficacy Chi-Square: 7.86; Substantially
vs Low Narcissim
vs Other Successful equivalent equivalent F: 8.43; p < 0.006 p < 0.096NS equivalent
Elite Adults
Adults (group 4)

Narcissistic patients showed higher anaclitic introjective depression, and relatively lower efficacy when compared to elite narcissists. However, when narcis-
sistic patients were juxtaposed against the control group of non-narcissistic patients, narcissistic patients exhibited a relatively greater capacity for efficacy
and social achievement. Elite narcissists had the highest ability for efficacy, social achievement and success than all other groups, demonstrating a con-
spicuous absence of anaclitic and introjective depression. Under conditions of low arousal elite narcissists evidenced a higher capacity for empathy than
both narcissistic patients and the control group of elite adults. Under conditions of low arousal, however, elite narcissists scored higher than the narcissistic
patients, but their empathic skills were equivalent to the control group of elite adults, contradicting DSM and psychodynamic assumptions that narcissism is
correlated with a low capacity for empathy. NS: result is statistically non-significant.

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 X. Sofra

colleagues, negating both descriptive and psychodynamic formulations associat-

ing narcissism with a low capacity for empathy. The two patient groups were
equivalent in their empathic skills, which were deficient under both low and
high arousal conditions.
In terms of overall level of functioning, the low arousal TAT card (Table 4)
gave different results than the high arousal TAT card (Table 5). Table 4 reflects
that in the absence of stress, some elite narcissists convincingly appear elevated
to the highest level of functioning, defined by sublimation, enriched empathy,
chivalry, and nobility.
This “excellence” is swiftly reversed during times of stress. Table 5 indicates
that under high arousal, most elite narcissists regress down to the borderline
(52.17%) or narcissistic levels (32%) of personality organization, being indistin-
guishable from mental patients, despite their vast differences in economic status
and social esteem. Only a small percentage of elite narcissists can maintain the
next to highest/neurotic level (4%), or the highest level of psychological func-
tioning (10%). The only difference between elite and patient narcissists is that
the elite ones do not seemingly deteriorate into the psychotic level, unlike a
small percentage of narcissistic patients who significantly regress under both low
arousal (10%), and high arousal conditions (16%).

6. Discussion
The findings of this clinical study elucidate a portrait of the narcissistic person-
ality disorder at two distinct levels of functioning. Elite narcissists appear em-
powered by their obsessive traits in accomplishing what their colleagues may
dismiss as unreachable. Their hysterical traits provide them with a seductive
warmth and charm designed to increase their popularity and manipulate others

Table 4. Low Arousal: Card 1 TAT/EARS MODES—Narcissistic Patients vs Elite Narcissists.

EARS Mode I EARS Mode II EARS Mode III EARS Mode IV EARS Mode V
Psychotic Borderline Narcissistic Neurotic Creativity
Number of Narcissistic Mentally ill Patients
2 (equivalent) 11 7 (equal) 4 1
(Group 1)
Number of Elite Narcissists (Group 2) 0 (equivalent) 5 7 (equal) 7 6

Under low arousal/non-stress conditions, 24% of elite narcissists appear to function at the highest level of personality organization; 28% function within the
neurotic level, and 28% function within the narcissistic level. Around 20% of them appear to function within the borderline level of personality organiza-
tion.

Table 5. High Arousal: Card 13MF TAT EARS MODES—Narcissistic Patients vs Elite Narcissists.

EARS Mode I EARS Mode II EARS Mode III EARS Mode IV EARS Mode V
Psychotic Borderline Narcissistic Neurotic Creativity
Number of Narcissistic Mentally ill Patients
4 11 (equivalent) 9 (equivalent) 1 (equal) 0 (equivalent)
(Group 1)
Number of Elite Narcissists (Group 2) 0 12 (equivalent) 8 (equivalent) 1 (equal) 2 (equivalent)

Under high arousal/stress conditions, elite narcissists regress down to the borderline (52.17%) or narcissistic levels (32%) of personality organization, and
only a small percentage of them can maintain their high level of psychological functioning within the neurotic (4%) or creativity levels (10%).

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X. Sofra

to their advantage. Their paranoid traits provide them with hypervigilance and
mistrust, instrumental in perceiving and anticipating hidden competition or
dangers in the environment. Their sadistic traits are interwoven with their
paranoid traits establishing a sophisticated line of defence expressed covertly by
passive aggression and avoidance, or overtly by confrontation and combative at-
tack, characterized by ruthlessness and lack of respect for human rights. In spite
of its pathological nature, sadism appears to be highly adaptive within the nar-
cissistic structure, primarily because it is utilized for self-enrichment and the re-
alization of ambitions and aspirations. Inherent in a sadistic organization is a
sense of pseudo-autonomy and being endowed with unlimited controlling power
over others. None of these is genuine or useful in providing the narcissist with
psychological growth or health. They are essential, however, in promoting a fa-
cade of superiority and grandiose perfection. From this perspective, their out-
standing empathic skills, especially under low-stress conditions, that are substan-
tially more advanced than their non-narcissistic colleagues, appear essential in
identifying others’ weaknesses to strategize their exploitation or defeat. Under
conditions of stress, elite narcissists regress to the psychological level of func-
tioning of narcissistic patients. However, the absence of depressive symptoma-
tology in their profiles suggests that elite narcissists may respond to adversity
with sadism.
One of the most important revelations of this experimental research was that
narcissistic individuals who entertain social acclaim and success in their prestig-
ious career positions, manifest the regressed psychopathology encountered in
mental patients diagnosed with narcissism. This finding may serve as a warning
to the possible adverse consequences of electing narcissistic leaders into a high
government position; or authorizing a charismatic, yet psychologically defective
individual to run a major corporation. The ruthless, enthralling compulsion to
maintain dominance and sovereignty, usually becomes conspicuous only after
the narcissistic individual has aggregated the necessary authority to relentlessly
exterminate opposition.
A second surprising revelation was the elite narcissists’ capacity for empathy
that surpassed both their non-narcissistic colleagues, and, as expected, the nar-
cissistic patients’ group. This empathic advantage was slightly compromised
under conditions of high arousal, to be equivalent to the empathic skills of non-
narcissistic successful individuals. But overall, narcissists did not manifest a “low
capacity for empathy” as previously postulated by both descriptive and psycho-
dynamic/psychoanalytic configurations of this personality constellation. This in-
consistency, however, may be due to semantics, involving an overinclusion of
incongruous concepts in the definition of “empathy”. Delineating a holistic, in-
tuitive insight of others is not synonymous with sympathy, in the sense that car-
ing is not inherent in the intellectual decipherment of others’ characters, needs
and feelings. In fact, methodical, impassionate analysis of people and situations,
void of compassion, is crucial in developing a winning strategy to attain success

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 X. Sofra

and dominance.
Both anaclitic and introjective depression, reflected by the dependency and
self-criticism dimensions of the DEQ respectively, were conspicuously inhibited
in thriving narcissists, reflecting the advantage of the narcissistic armour, com-
bined with ruthless ambition that compels them to disown feelings of depression
or guilt, to unobtrusively rise to wealth and power. Interestingly, despite their
severe anaclitic and introjective pathology, narcissistic patients were higher in
efficacy, social achievement, and self-confidence than non-narcissistic patients,
once again confirming the protective shield of narcissism and its forte in crafting
self-enhancement illusions.
Although narcissistic patients share a lot of characteristics with their privi-
leged counterparts, their prominent masochism drives them into self-deprecation.
Being a victim has the benefit of virtue, propriety and gentility, in contrast to
their aggressor onto whom they have projected all their hostility and sadism; and
who is now under the obligation of atonement to nurture and shelter them.
Their anaclitic depression and harsh self-criticism attenuate their dependency,
so they use their hysterical traits to incapacitate themselves, appearing disorgan-
ized, careless, and in desperate need of others, actively sabotaging any career
prospects. They use their paranoid traits to scrutinize any threat that could po-
tentially separate them from their significant others. Their only route of self-
enhancement is attaching themselves to an elite narcissist, often exhibiting ero-
tomania, blind idealization, or fanatic loyalty. This low-level narcissistic type
serves as the primary source of power of the charismatic narcissistic leader, ren-
dering both narcissistic follower and its idolized authority equally dangerous. It’s
the low-level narcissist’s glorified admiration that supports and establishes the
dominance of a toxic, vicious tyrant. This sadomasochistic alignment, where
low-and-high level narcissists feed from each-others’ pathology, is often concre-
tized in the impossibility of escape and manifested in cults and authoritarian so-
cieties.
Study weaknesses are associated with the descriptive constructs composing
psychometric instruments such as SIDP and SIDP-R that provide specificity, yet,
limited psychological depth, juxtaposed against the elaborate richness of psycho-
dynamic assessment tools like the EARS, based on often fluid multifaceted con-
cepts, rendering them incompatible with statistical calculations. The inherent
difficulty in interpreting projective tests may have affected the conclusions de-
rived from the empathy dimension; although interrater agreement was statisti-
cally significant. The sadism and masochism dimensions that are part of the
SIDP-R, were eventually deleted from further revisions of the diagnostic statisti-
cal manual, on the premise that they represented aspects of other personality
disorders, rather than encompassing complete separate entities. Another per-
sonality type that never made it into the DSM, and which could have con-
founded results, is the hypomanic personality disorder, postulated by Akhtar in
1988 [58]. This type resembles narcissistic and histrionic types in terms of the

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X. Sofra

grandiosity, ambition and ostentatious, theatrical behaviours; however, they are

distinguished by their affinity to eccentricity, mysticism, and cyclothymic affec-
tive organization, manifesting a variety of contradictory feelings, and a con-
glomeration of opposing psychological states intertwined into a paradoxical, yet,
harmonious personality constellation.
In conclusion, we combined descriptive and psychodynamic diagnostic sys-
tems in an effort to present a more enriched and comprehensive perspective of
narcissism; however, the unbridged inconsistencies between symptoms and a
dynamic personality exploration may have ultimately confounded our results.

Acknowledgements
The author would like to thank Dr Arnold Wilson for his inspiring guidance on
narcissistic concepts and for developing the Epigenetic Assessment Rating Scale.
Special thanks to Dr Elsa Ronningstam for her insights on narcissism, and her
instructive clarification regarding differential diagnosis.

Funding
No funding was received by a third party or institution.

Conflicts of Interest
The author has no conflicts of interests to disclose.

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