Heal NPD

In this episode, Dr. Mark Ettensohn explores the concept of annihilation anxiety and its role in narcissistic pathology and other personality disorders.
Beginning with a clinical vignette involving childhood emotional and physical abuse, the episode examines what can happen when a child’s separate thoughts, feelings, and perceptions become psychologically threatening to a caregiver. A child may depend on a parent for love, safety, and recognition while simultaneously discovering that important parts of his own subjective experience cannot safely coexist with the parent’s psychological reality. Under these conditions, psychological separateness itself can become associated with danger.
Dr. Ettensohn describes this relational configuration as a kind of zero-sum psychological system. When two minds cease to confirm one another, it can feel as though only one can remain intact. Either one person must surrender some part of their subjective experience, or the incompatible experience of the other person must be changed, discredited, controlled, or destroyed. Over time, children raised within these dynamics may internalize the expectation that maintaining a separate mind threatens attachment, identity, or psychological survival.
The episode then considers narcissistic pathology as one possible adaptation to this problem. Idealization and admiration can provide refuge from annihilation by supporting a coherent and valued sense of self. But when that self remains dependent upon confirmation from other people, criticism, disagreement, or rejection can reactivate the original threat. Familiar narcissistic defenses such as grandiosity, projection, devaluation, and rage can then function as attempts to prevent an intolerable representation of the self from existing in either person’s mind.
Dr. Ettensohn argues that this process is not exclusive to narcissism. Different forms of personality pathology may organize annihilation anxiety differently. Separateness may be surrendered through dependency, destabilize the experience of self in borderline states, become experienced as persecutory threat, or be avoided through schizoid or avoidant withdrawal. Despite their differences, these adaptations can share a common psychological problem: difficulty maintaining a stable experience of self while remaining in relationship with a genuinely separate other.
Ultimately, the episode proposes annihilation anxiety as a central conflict in personality pathology and examines how complex relational trauma can reproduce itself across generations. What gets transmitted is not simply a collection of abusive behaviors, but a way of organizing relationships in which psychological separateness becomes dangerous and one person’s subjectivity may have to disappear so that another’s can remain intact.
Works Cited: Neuman, C. J. (2012). Impact of borderline personality disorder on parenting: Implications for child custody and visitation recommendations. Journal of Child Custody, 9(4), 233–249. https://doi.org/10.1080/15379418.2012.748350
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About Heal NPD
Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, Narcissistic Personality Disorder, and related personality difficulties. We provide comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

In this episode, Dr. Mark Ettensohn asks a simple question: What would happen if we talked about depression the way we currently talk about narcissism?
Through a thought experiment, the episode imagines an alternate reality in which depression has become the focus of the same kind of online discourse that now surrounds narcissism. Social withdrawal becomes “withholding.” Loss of motivation becomes laziness. Preoccupation with painful internal states becomes selfishness. Irritability becomes hostility. Difficulty accepting help becomes an unwillingness to take accountability. Gradually, recognizable features of a mental disorder are stripped of their psychological context and reinterpreted as evidence of a morally defective kind of person.
The thought experiment then expands. Stories from people who have been hurt by depressed partners, parents, friends, and coworkers begin supplying additional characteristics of the “depressed person.” Lying, cheating, manipulation, neglect, controlling behavior, and abuse are folded into the category, not because these behaviors have been shown to characterize depression, but because some people with depression also engage in them. 
Dr. Ettensohn argues that something similar has happened in popular discourse about narcissism. Behaviors such as lying, cheating, gaslighting, manipulation, coercion, love bombing, vindictiveness, and abuse are increasingly presented as characteristics of “the narcissist,” even though none are specific to narcissistic pathology. The result is a circular process in which harmful behavior is used to identify someone as a narcissist, while the behavior of people already identified as narcissists is then used as evidence for what narcissists supposedly do.
The episode also examines why Narcissistic Personality Disorder may be particularly vulnerable to this process, because unlike many psychiatric diagnoses, the traditional diagnostic criteria for NPD already emphasize objectionable interpersonal manifestations such as entitlement, exploitation, impaired empathy, arrogance, and grandiosity. 
Ultimately, the episode argues for putting psychology back into the cultural conversation about narcissism. When narcissistic pathology is reduced to an ever-expanding collection of frightening, hurtful, or objectionable behaviors, the psychological organization that might make those behaviors intelligible disappears. What remains may still use the language of psychology, but instead of a model of a mind, it becomes the description of a villain.
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About Heal NPDHeal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, Narcissistic Personality Disorder, and related personality difficulties. We provide comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

In this episode, Dr. Mark Ettensohn examines what self-esteem actually looks like in pathological narcissism and why common explanations such as “low self-esteem hidden beneath grandiosity” or “grandiosity masking shame” oversimplify a much more complicated psychological process. 
The episode begins by examining self-esteem as a regulatory system rather than a fixed quantity that a person either has or does not have. Healthy self-esteem is generally stable, realistic, and basically positive. Dr. Ettensohn explains how pathological narcissism can involve difficulties in all three areas, producing self-appraisals that are unstable, highly reactive to circumstances, and capable of shifting between unrealistically positive and unrealistically negative views of the self.
The discussion explores the grandiose and vulnerable self-states associated with pathological narcissism. Grandiosity can involve genuine feelings of superiority, exceptionalism, or importance, while vulnerable states may involve shame, humiliation, inadequacy, depression, envy, or anxiety. These states can alternate, overlap, and interact in complicated ways. Neither necessarily represents the person's “real” self hiding underneath the other.
Dr. Ettensohn also discusses the development of self-esteem regulation, including the interaction between temperament, heritable traits, relationships, and developmental experience. Rather than reducing pathological narcissism to a single cause, contemporary models understand personality pathology as emerging through complex interactions between the characteristics people bring into the world and the experiences through which their personalities develop.
The episode then considers behaviors frequently associated with pathological narcissism, including arrogance, entitlement, idealization, devaluation, exploitation, and impaired empathy. These features are often discussed as though they stand apart from problems of self-esteem. Dr. Ettensohn explains how they can instead function within a larger system of self-esteem regulation, particularly when grandiosity is recruited to maintain or restore a threatened sense of self.
At the same time, none of these features by itself establishes pathological narcissism. People can be arrogant, entitled, grandiose, low in empathy, or insecure without having NPD. They can also have unstable or chronically low self-esteem without being narcissistic. Pathological narcissism refers to the larger organization of these features: the vulnerability of the self-esteem system, grandiose and vulnerable self-states, and the characteristic regulatory strategies used to maintain, protect, or restore the person’s sense of self.
Ultimately, the episode challenges attempts to reduce narcissistic psychology to a single hidden truth beneath the surface. Grandiosity can sometimes defend against shame, but that particular dynamic should not be mistaken for an explanation of the disorder as a whole.⸻Additional ResourcesWebsite: https://healnpd.orgNewsletter: https://healnpd.substack.com
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About Heal NPDHeal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, Narcissistic Personality Disorder, and related personality difficulties. We provide comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

In this episode, Dr. Mark Ettensohn examines the circular logic that often appears in popular “narcissistic abuse” discourse and how it can create a closed system for interpreting other people’s behavior.
The episode begins with a pattern Dr. Ettensohn has repeatedly encountered online: once someone concludes that another person is a narcissist, virtually any response can become further evidence of narcissism. Disagreement becomes an inability to tolerate criticism. Anger becomes narcissistic rage. Denial becomes DARVO. Withdrawal becomes the silent treatment. An apology becomes manipulation or hoovering. Even evidence that contradicts the original conclusion can be reinterpreted as proof that the narcissist has successfully deceived others.
Dr. Ettensohn argues that this creates an essentially unfalsifiable framework. If both an accusation and its denial can be treated as evidence of guilt, there is no independent standard by which the original interpretation can be tested or revised. Rather than asking what explanation best accounts for another person’s behavior, the process begins with a conclusion and assembles evidence around it.
Drawing on his experience conducting psychological assessments, Dr. Ettensohn discusses how this reasoning can persist even when a person does not meet criteria for Narcissistic Personality Disorder or pathological narcissism. He explores how the extensive vocabulary of popular narcissistic-abuse content can encourage people to infer hidden motives and psychological states from ambiguous behavior while becoming increasingly resistant to alternative explanations.
The episode also challenges the widespread conflation of pathological narcissism with abuse. People with NPD can behave abusively, but abusive behavior does not itself establish the presence of pathological narcissism. Recent research has likewise raised questions about treating pathological narcissism as a general explanation for intimate partner abuse.
Ultimately, the discussion asks a basic epistemological question: If every possible response can be interpreted as evidence that someone is a narcissist, what evidence could ever show that the conclusion was wrong?
References:Day, N. J. S., Kealy, D., Biberdzic, M., Green, A., Denmeade, G., & Grenyer, B. F. S. (2025). Coercive control and intimate partner violence: Relationship with personality disorder severity and pathological narcissism. Personality and Mental Health, 19(4), e70038.
https://onlinelibrary.wiley.com/doi/full/10.1002/pmh.70038
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Website: https://healnpd.orgNewsletter: https://healnpd.substack.com
Purchase Unmasking Narcissism: A Guide to Understanding the Narcissist in Your Life: https://amzn.to/3nG9FgH
LISTEN ON APPLE PODCASTS: https://rb.gy/cklpumLISTEN ON AMAZON MUSIC: https://rb.gy/g4yzh8
  About Heal NPDHeal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, Narcissistic Personality Disorder, and related personality difficulties. We provide comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

In this follow-up to a previous episode, Dr. Mark Ettensohn examines a central problem in the way narcissism is commonly discussed online: the assumption that abusive behavior is sufficient evidence of narcissism.
The episode argues that this conclusion arises, in part, from a longstanding problem in the DSM diagnostic criteria for Narcissistic Personality Disorder. Many of the interpersonal characteristics traditionally associated with NPD, including entitlement, impaired empathy, exploitation, arrogance, and refusal to take responsibility, are also common features of abusive relationships in general. As a result, virtually any abusive relationship can appear “narcissistic” without establishing that pathological narcissism is actually present.
Dr. Ettensohn explores how this lack of specificity has contributed to the widespread popularity of the concept of “narcissistic abuse,” and why it has become increasingly difficult to distinguish abusive behavior from pathological narcissism itself. He argues that contemporary research has moved toward understanding pathological narcissism as a disorder of identity and self-esteem regulation characterized by fluctuating grandiose and vulnerable states, rather than simply a collection of observable interpersonal behaviors.
The episode also examines how popular discussions of narcissism often continue to rely on the older behavioral framework while separating the term “narcissism” from its underlying clinical construct. Dr. Ettensohn argues that this creates conceptual confusion, contributes to public stigma surrounding NPD, and encourages people to mistake abuse itself for evidence of narcissistic pathology.
Ultimately, the discussion asks a simple question: When does abusive behavior actually indicate pathological narcissism, and when are we simply describing abuse?
To see the video this follows up: https://youtu.be/lcIEM7IVXxk
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About Heal NPD
Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, Narcissistic Personality Disorder, and related personality difficulties. We provide comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

 
About Heal NPD
Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

Dr. Mark Ettensohn examines the common claim that personality disorders such as narcissistic personality disorder (NPD) are either caused by trauma or are primarily genetic. He argues that this framing presents a false dichotomy and does not reflect how personality development is understood in contemporary psychology.
The discussion begins by reconsidering what psychologists mean by the word trauma. Rather than treating trauma as a particular kind of event, Dr. Ettensohn explores the idea that trauma is better understood as the psychological injury resulting from life experiences. This distinction helps explain why children raised in the same family can have very different developmental outcomes despite sharing many of the same experiences.
The episode also examines the role of temperament and other heritable factors in personality development. While genetic predispositions influence how individuals experience and respond to their environments, they do not determine personality disorders in isolation. Instead, personality emerges through the ongoing interaction between biology and developmental experience.
Finally, Dr. Ettensohn addresses common arguments based on brain imaging and twin studies, explaining why these findings are often misunderstood in discussions about heritability. The episode considers the importance of construct validity, operationalization, and measurement when interpreting research on personality disorders, arguing that simplistic claims about either trauma or genetics fail to capture the complexity of human psychological development.
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Website: https://healnpd.orgNewsletter: https://healnpd.substack.com
Purchase Unmasking Narcissism: A Guide to Understanding the Narcissist in Your Life: https://amzn.to/3nG9FgH
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About Heal NPD
Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

Dr. Mark Ettensohn examines the concept of “narcissistic abuse” and explains why he no longer considers it a coherent psychological construct.
Using the comment from a viewer as a starting point, the discussion explores a common misconception: that skepticism toward the concept of narcissistic abuse reflects a lack of empathy for victims. Dr. Ettensohn argues that his concern is not with the reality of abuse or the suffering of those who experience it, but with the explanatory framework that has developed around the term.
The episode examines the concept through the lens of construct validity, asking what psychological phenomenon the term actually refers to and whether it identifies a distinct form of abuse beyond categories that are already well established in psychology. The discussion considers the problems of operationalization, the distinction between observation and inference, and why labeling abuse according to the presumed diagnosis of the perpetrator differs from defining abuse by the harm it causes.
Dr. Ettensohn also revisits his own earlier use of the term, explaining how his thinking has evolved over time. He distinguishes between psychoanalytic concepts such as narcissistic injury and the contemporary online usage of “narcissistic abuse,” arguing that these represent fundamentally different theoretical models.
Finally, the episode explores how explanatory frameworks shape memory and interpretation, and why concepts that incorporate assumptions about another person’s motivations or diagnosis may become difficult to evaluate critically. Throughout, the discussion argues for greater conceptual precision in psychology while emphasizing that questioning a psychological construct is not the same as questioning the reality of abuse.
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About Heal NPD
Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org

This episode continues the Heal NPD Seminar Series with Dr. Mark Ettensohn and associate Deanna Young, Psy.D.
In this session, the group discusses the article “A Mentalizing Approach for Narcissistic Personality Disorder: Moving From ‘Me-Mode’ to ‘We-Mode’” (Choi-Kain, Simonsen, & Euler, 2022), which explores how Mentalization-Based Treatment (MBT) can be applied to the treatment of narcissistic personality disorder.
The paper argues that many of the challenges clinicians encounter when working with narcissistic patients can be understood through the lens of attachment, mentalization, and epistemic trust. Rather than viewing narcissistic pathology primarily as a problem of entitlement, grandiosity, or lack of empathy, the authors conceptualize it as a disturbance in the capacity to understand oneself and others in psychological terms and to learn from emotionally meaningful relationships.
The discussion explores the article’s central proposal that treatment involves helping patients move from a self-focused “me-mode” toward a more collaborative “we-mode,” in which multiple perspectives can be held in mind simultaneously. Particular attention is given to the ways in which narcissistic adaptations interfere with trust, intimacy, and therapeutic engagement.
Along the way, the conversation examines several key MBT concepts, including:
* Epistemic trust and distrust* Nonmentalizing modes, including pretend mode, psychic equivalence, and teleological thinking* Marked contingent mirroring* The therapeutic alliance as a vehicle for psychological change* Why confrontation and pressure for change can sometimes reinforce narcissistic defenses rather than weaken them
The discussion also considers the broader cultural discourse surrounding narcissism and contrasts popular approaches that emphasize accountability, confrontation, and labeling with psychodynamic and attachment-based approaches that emphasize understanding, curiosity, and the gradual development of trust.
Finally, the group reflects on the practical realities of psychotherapy with narcissistic patients, including the pressures created by partners and family members seeking rapid change, the tendency for therapists to become caught in power struggles, and the challenge of maintaining a mentalizing stance in the face of difficult interpersonal dynamics.
Key themes include:
* Mentalization-Based Treatment (MBT) and narcissistic personality disorder* Attachment theory and personality pathology* Epistemic trust as a foundation for psychological growth* The relationship between vulnerability and grandiosity* Nonmentalizing modes of experience* The role of empathy, curiosity, and validation in treatment* Clinical challenges in working with narcissistic patients
This series is intended for clinicians, trainees, and viewers seeking a nuanced, clinically grounded understanding of narcissism beyond popular discourse.
To learn more about our work, visit:www.HealNPD.org
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Citation:
Choi-Kain, L. W., Simonsen, S., & Euler, S. (2022). A Mentalizing Approach for Narcissistic Personality Disorder: Moving From “Me-Mode” to “We-Mode.” American Journal of Psychotherapy, 75(1), 38–43.
Full text link: https://www.psychiatryonline.org/doi/epdf/10.1176/appi.psychotherapy.20210017

This is the third part of a three-part exploration of narcissistic personality style at the neurotic level of personality organization.
In this episode, Dr. Ettensohn examines the defensive architecture of neurotic-level narcissism, including the characteristic defenses that allow individuals to manage conflict, preserve relationships, and maintain self-esteem without resorting to the identity fragmentation or reality distortion seen at more severe levels of personality organization.
Drawing on the Defense Mechanisms Rating Scale (DMRS), this episode explores obsessional defenses such as isolation of affect, intellectualization, and undoing, as well as neurotic defenses including repression, reaction formation, and displacement. Through clinical examples, personal reflections, and portrayals from film and literature, Dr. Ettensohn illustrates how these defenses shape emotional experience, interpersonal relationships, and the therapeutic process.
The episode also examines how narcissistic concerns manifest at the neurotic level, including struggles with self-worth, dependency, vulnerability, perfectionism, and grief. Particular attention is given to transference, countertransference, and the unique opportunities and challenges that emerge in psychotherapy with neurotic-level narcissistic personalities.
While neurotic-level functioning represents a profound developmental achievement, it also introduces new emotional realities. As the capacity for integration grows, so too does the capacity to experience loss, guilt, limitation, and sorrow. The movement toward greater psychological health is not the elimination of suffering, but the ability to bear it without abandoning oneself or others.
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About Heal NPDHeal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.
Learn more or inquire about services: https://healnpd.org