The Relationship between Neuromuscular Dysfunction of the Bladder and Pathological Narcissism

Introduction

In neurology, neuromuscular dysfunction of the bladder, as well as hyperactive («stress-induced») bladder syndrome, refers to «chronic pelvic pain syndrome» (CPPS). This disorder in moderate to severe form is observed in 6.5–10% of men in the general population and should be understood as the result of complex interactions of psychological factors with somatic dysfunctions. It can be perceived as a somatoform disorder [1]. To this day, there is uncertainty about the etiology of this disorder. Research in the field of neurology has so far focused mainly on somatic factors. However, according to the phenotyped multimodal diagnostic system UPOINT, the interaction of infectious, genitourinary, neurological, and psychological factors that are represented by the patient’s mental state (depression, hypochondriacal disorder, anxiety spectrum disorders, somatoform disorder, PTSD) should be considered [2].

To this day, the psychological factors involved in CPPS in men have not been sufficiently studied in Russian practice, unlike our foreign colleagues [3]. To assess psychological factors in the UPOINT system, attention is often paid to symptoms of mental ill-being, but little is paid to the patient’s personal organization. It has been shown that men with chronic prostatitis often (up to 63%) have borderline personality functioning, personality disorders in the narcissistic sphere predominate, narcissistic personality disorder (narcissism disorder) is present with difficulties in understanding both their own mental state and other people (the ability to mentalize [4, 5, 6].

Changes in the narcissistic configuration, pathological narcissism in a patient in neurourology is an important and underestimated clinical problem associated with significant functional outcomes during treatment, and the risks of developing a refractory course.

According to the hierarchical model of A. Pincus and M. Lukovitsky, pathological narcissism refers to a deficit in the regulation of self-esteem, including maladaptive mechanisms for restoring and maintaining one’s own “I” or self-image [6].

Research Methods

• The scale of pathological Narcissism (Pathological Narcissism Inventory, PNI), which includes 52 questions. The assessment of grandiosity includes exploitative interpersonal behavior, immersion in grandiose fantasies and presumptuous altruistic behavior. Vulnerability consists of admiring self-esteem, hiding perceived flaws and needs, devaluing others, and having anger at limitations.
• Somatization was assessed using a health assessment scale (Patient Health questionnaire, PHQ-15), which allows you to assess which of the 15 symptoms, including gastrointestinal ones, the patient has been concerned about in the last 3 months;

The presence and degree of symptoms of anxiety and depression were assessed using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scales Pain Catastrophizing Scale (PCS).

The results of the study. Men with CPPS have pronounced symptoms of generalized anxiety disorder and depression (feeling of emptiness), which indicates the presence of a state of threat to the “I” (the threatening part in the “I”). The tendency to somatization of affect as a protective mechanism and a way of avoiding internal distorted standards.

On the part of pathological narcissism, men with CPPS experience fluctuations between assertive grandiosity and vulnerability, and there may be bouts of insecurity that destroy a sense of grandiosity or singularity (uniqueness).

More pronounced changes are observed on the part of narcissistic fragility (vulnerability) than grandiosity, which reflects the vulnerability of the “I” (hypersensitivity), a tendency to anxiety arousal, disorders in emotional self- regulation (fluctuations in self-esteem, feelings of shame). Following H. Kogut, it can be said that these patients have diffuse narcissistic vulnerability. The difficulty for these patients lies in the pain and suffering that accompany the presence of such disparate “split off” or non-integrated parts of the Self, which leads to the defensive use of maladaptive intrapersonal and interpersonal tactics to maintain a “stable” sense of self.

The presence of narcissistic fragility in patients with CPPS suggests that they carry traumatic narcissism (narcissistic trauma), which poses a risk of developing PTSD, since this injury is perceived as a threat to the “I”.

There are high rates of self-sacrifice and self- aggrandizement, as the deliberate use of altruistic acts to maintain an “inflated” image of “Me” (for example, “I work”, “I eat”, “I try”), as well as the presence of grandiose fantasies (to fight, “win”, “achieve”, “to prove yourself”, which perform the function of artificial mobilization. In order to cope with unstable self-esteem, patients with CPPS can create an exaggerated sense of superiority, uniqueness, plunging into grandiose fantasies.

On the part of narcissistic fragility as a form of maladaptive or poorly protected narcissism, there is a pronounced demanding rage, which reflects a tendency to put pressure on oneself (self-sabotage), to be dissatisfied with oneself, to react with anger (anger, resentment, irritation) in cases where expectations from a significant other are not satisfied or do not meet internal strict standards (“norms”). Patients can drown out this demanding rage with alcohol.

Unstable self-esteem prevails in the form of fluctuations in the sphere of self-esteem, recognition of its failures in the absence of external sources of recognition, “reassurance”. support, admiration (feedback from another, for example, close people, doctors). Devaluation manifests itself in the absence of spontaneous, flexible interest in other people who do not demonstrate the necessary admiration, desired behavior. There is a sense of shame for the excessive need for recognition from those who once disappointed, often a father figure. The presence of narcissistic fragility can be understood as a pathological defense against negative emotions and reflects their reduced resilience.

Patients with CPPS seem to lack appropriate strategies to deal with strong emotions, and they rely only on protective mechanisms (e.g. somatization, denial) to regulate their emotions and self-esteem. They feel ashamed of their needs and ambitions.

Significant positive associations have been found between somatic urological symptoms and symptoms of depression, anxiety, catastrophization of pain, as well as between somatic urological symptoms and narcissistic grandiosity and vulnerability in patients with CPPS.

Narcissistic fragility in patients with CPPS is associated with the presence and severity of symptoms of depression, which is consistent with evidence that this form of pathological narcissism is associated with a wide range of symptoms of disorders of both the affective and psychotic spectrum. Anxiety in poorly protected narcissistic individuals (with fragility) to be separated from others and their desire to be recognized can lead to an excessive search for conformity, which can lead to somatoform symptoms (abdominal pain, gastrointestinal specific anxiety, nausea, itching), and they can be associated with a sense of meaninglessness, which refers to psychological insecurity or negative emotionality. Note that the presence of self-sacrifice in patients with CPPS /self-elevation, unstable self-esteem and demanding rage affect all indicators of psychological well-being, as well as the catastrophization of pain.

The relationship between grandiosity and somatic symptoms in men is less consistent with theoretical assumptions. According to early research, men with grandiose features were more likely to approve of physical integrity and even superiority. However, the men in our study voluntarily agreed to psychological examination and psychotherapy. Perhaps for men with grandiose facial features, the expression of physical complaints is preferable to the experience of crumpled self-perception. Thus, physical pain can perform a protective function, saving men from further erosion of self-representation. It may also conform to socialized gender norms that emphasize men’s physical attractiveness and discourage men from expressing emotional distress.

It has been shown that the tendency to somatize affect in the form of painful manifestations is influenced by pathological narcissism, the presence and severity of anxiety disorder, depression and pain catastrophizing. The results of our study indicate how important it is to pay attention to the characteristics of personality organization (pathological narcissism) in the clinical picture of CPPS. Pathological narcissism contributes to the development of somatic symptoms due to the patient’s increased sensitivity to physical sensations, which, in turn, affects the perception of somatic distress. However, the results of our study force us to state that we are still far from controlling all the pathological aspects of CPPS, low tolerance for coping with stress, deterioration of mood, catastrophic beliefs, narcissistic vulnerability, which makes the experience of pain truly a source of suffering and requires, in addition to medical, psychotherapeutic tactics aimed at strengthening psychological stability in this group of patients.