- Email: [email protected]
Narcissistic Personality Disorder
Narcissistic Personality Disorder Salman Akhtar
JeffersonMedicalCollege
I. II. III. IV.
Manifestations Distinction from Related Conditions Intrinsic Nature Treatment
beginning with Sigmund Freud's elucidation of the concept of narcissism. Freud published his seminal paper "On Narcissism" in 1914. He defined narcissism as the concentration of libidinal interest upon one's ego and distinguished primary from secondary narcissism. The former was a normal phenomenon of infancy, the latter a result of withdrawal of interest from the outer world. Freud noted that human attachments are of two types: anaclitic and narcissistic. The former are evident when we are involved with those who nourish and protect us and the latter when we are involved with those who merely reflect us (the way we are, or were, or will be). In essence, the narcissistic relationship is nothing but thinly veiled sell-affirmation. While avoiding character typology in this paper, Freud did refer to individuals who compel our interest by the narcissistic consistency with which they manage to keep away from their ego anything that would diminish it." However, it was not until 1931 that he described the "narcissistic character type."
Narcissism Emotional investment into the self. When normal, it leads to sustained self-regard and mature aspirations. When pathological, it is accompanied by inordinate demands upon the self, excessive dependence upon acclaim from others, and deteriorated capacity for interpersonal relations. Personality Disorder A pervasive pattern of chronically maladaptive behavior which is a source of constant interpersonal problems. Personality disorders are ego-syntonic, i.e., such individuals are not aware of their own personalities as being deviant or abnormal. They suffer from the interpersonal consequences of their behavior but they do not recognize their own role in the origin and perpetuation of these problems. Such individuals are therefore unlikely to seek professional advice although they may consent to it if this is urged by others or forced by social repercussions of their behavior.
The subject's main interest is directed to self-preservation:he is independent and not open to intimidation. His ego has a large amount of aggressiveness at its disposal, which also manifests itself in readiness for activity. In his erotic life loving is preferred above being loved. People belongingto this type impress others as being "personalities"; they are especially suited to act as a support for others, to take on the role of leaders and to give a fresh stimulus to cultural development or to damage the established state of affairs.
NARCISSISTIC PERSONALITY DISORDER is a newly recognized diagnostic entity in clinical psychiatry. It was introduced into "official" psychiatric nomenclature in 1980 with the publication of the third edition of the American Psychiatric Association's Di-
This description is generally viewed as the pioneering portrayal of narcissistic personality disorder. The fact, however, is that a 1913 paper by Ernest Jones, one of Freud's distinguished pupils, also contained signi-
agnostic and Statistical Manual of Mental Disorders (DSM-III). There is, however, evidence that the concept had been evolving since the turn of the century
271
Copyright 9 1998 by Academic Press. All rights of reproduction in any form reserved.
272
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Narcissistic Personality Disorder
ficant details regarding the phenomenology of this condition. Using the term "God Complex" for their condition, Jones portrayed such individuals as excessively admiring of themselves, having omnipotent fantasies, being exhibitionistic, and scornful of others. Such grandiosity is, at times, masked by caricatured modesty, pseudohumility, and a pretended contempt for materialistic aspects of life. Over the subsequent decades, many other psychoanalysts contributed to the study of narcissistic personality. Prominent among these were Robert Waelder, Wilhem Reich, Christine Olden, Helen Tartakoff, and John Nemiah. These authors clearly recognized this condition though often without designating it as such. They noted that the central feature of this condition, grandiosity, is a defensive maneuver against feelings of inferiority which they traced to severe frustrations during early childhood. In the 1970s the publication of two psychoanalytic books breathed new life in the study of narcissistic personality disorder: The Analysis of the Self (1971) by Heinz Kohut and Borderline Conditions and Pathological Narcissism (1975) by Otto Kernberg. The views of Kohut and Kernberg are summarized below. Suffice it to say here that their works stirred up considerable controversy and mobilized further interest in investigating the true nature of narcissistic personality disorder. Among those who made subsequent major contributions are Sheldon Bach, Ben Bursten, Mardi Horowitz, Arnold Modell, Arnold Rothstein, and Vamik Volkan. Finally, when in 1980 the DSM-III included narcissistic personality disorder as a separate diagnostic entity, an official imprimatur was added to the evolving concept. The DSM-IV retained the condition with only minor modifications of its diagnostic criteria.
I. MANIFESTATIONS
The cardinal feature of narcissistic personality disorder is heightened narcissism. Individuals with this disorder display grandiosity, intense ambition, and an insatiable craving for admiration. Their consuming self-interest renders them incapable of appreciating and understanding the independent motivations and needs of others. Consequently, they come across as cold, unempathic, exploitative, and having little concern for those around them.
The clinical features of narcissistic personality disorder involve six areas of psychosocial functioning: (i) self-concept, (ii) interpersonal relations, (iii) social adaptation, (iv) ethics, standards, and ideals, (v) love and sexuality, and (vi) cognitive style. In each of these areas there are "overt" and "covert" manifestations. These designations do not necessarily imply their conscious or unconscious existence although such topographical distribution might also exist. In general, however, the "overt" and "covert" designations denote seemingly contradictory phenomenological aspects that are more or less easily discernible. Moreover, these contradictions are not restricted to the individual's self-concept but permeate his interpersonal relations, social adaptation, love life, morality, and cognitive style. Narcissistic individuals have a grandiose selfconcept. They give an appearance of self-sufficiency and are preoccupied with achieving outstanding success. Covertly, however, they are fragile, vulnerable to shame, sensitive to criticism, and filled with morose self-doubts and feelings of inferiority. Their interpersonal relations are extensive but exploitative and driven by an intense need for tribute from others. They are unable to genuinely participate in group activities and, in family life, value children over the spouse. Inwardly, they are deeply envious of others' capacity for meaningful engagement with life. They attempt to hide such envy by scorn for others; this may, in turn, be masked by pseudo-humility. Capable of consistent hard work, narcissistic individuals often achieve professional success and high levels of social adaptation. However, they are preoccupied with appearances and their work is done mainly to seek admiration. The overly zealous vocational commitment masks a dilettante-like attitude, chronic boredom, and gnawing aimlessness. Their ethics, standards, and ideals display an apparent enthusiasm for sociopolitical affairs, a caricatured modesty, and pretended contempt for money in real life. At the same time, they are often quite materialistic, ready to shift values to gain favor, irreverent toward authority, and prone to pathologic lying and cutting ethical comers. A similar contradiction is evident in the realm of love and sexuality. Overtly, narcissistic individuals are charming, seductive, and given to extramarital affairs, even promiscuity. Covertly, however, they draw little gratification beyond physical pleasure from sexuality
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
273
Narcissistic Personality Disorder
and are unable to have deep and sustained romantic relations. Moreover, they seem unable to genuinely accept the incest taboo and are vulnerable to sexual perversions. Superficially, their cognitive style suggests a decisive, opinionated, and strikingly supple intellect. However, their knowledge is often limited to trivia ("headline intelligence") and they are forgetful of details. Their capacity for learning is also compromised since learning forces one to acknowledge one's ignorance and they find this unacceptable. They are articulate but tend to use language and speaking for regulating self-esteem rather than communicating. In sum, narcissistic personality disorder is characterized by a defensively inflated self-concept which is fueled by fantasies of glory, protected by being constantly admired for social success, and buttressed by scornful devaluation of those who stir up envy. Underneath this grandiose self-concept (not infrequently built around some real talent or special aptitude) lie disturbing feelings of inferiority, self-doubt, boredom, alienation, and aimlessness.
tal states. They are less tolerant of aloneness, more angry, and have a poorer capacity for sustained work than narcissistic individuals. [See BORDERLINE PERSONALITYDISORDER.] Both antisocial and narcissistic individuals dream of glory and can lie, cheat, and indulge in ethically dubious acts to achieve success. However, in narcissistic personality such disregard of conventional morality is hidden, occasional, and cautious whereas in antisocial personality it is open, frequent, ruthless and calculated. [See ANTISOCIALPERSONALITYDISORDER.] Both paranoid and narcissistic individuals are grandiose, emotionally stilted, envious, sensitive to criticism, and highly entitled. However, the paranoid individual is pervasively mistrustful and lacks the attention-seeking charm and seductiveness of the narcissist. The cognitive style of the two types of individuals differs in a striking way. The narcissist is inattentive to real events and forgetful of details. The paranoid, in contrast, has a biased but acutely vigilant cognition. [See PARANOIA.]
III. INTRINSIC NATURE II. DISTINCTION FROM RELATED CONDITIONS Individuals with narcissistic personality disorder have superficial resemblances to those with compulsive personality disorder. Both types of individuals display high ideals, great need for control, perfectionism, and a driven quality to their work. However, the compulsive seeks perfection while the narcissistic claims it. Consequently, the compulsive is modest, the narcissist haughty. The compulsive loves details that the narcissist casually disregards. The compulsive has a high regard for authority and strict inner morality, while the narcissist is often rebellious and prone to cutting ethical corners. [See OBSESSIVE--CoMPULSIVE
DISORDER.] Three other characterological constellations need to be distinguished from narcissistic personality disorder: borderline, antisocial, and paranoid personality disorders. Both borderline and narcissistic individuals are self-absorbed and vacillating in their relationships. Borderline individuals, however, show a greater propensity for disorganization into really regressed men-
In the realm of probable causes and the intrinsic nature of narcissistic personality disorder the views of Heinz Kohut and Otto Kernberg form the two major, if sharply divergent, contemporary perspectives. According to Kohut, the origin of narcissistic personality disorder resides in faulty parental empathy with the child. Kohut posits that a growing child needs an enthusiastically responsive audience ("mirroring") for his or her activities and achievements. When such mirroring is deficient, the child's ordinary pride and associated healthy need to be affirmed take on an insistent and unhealthy exhibitionistic quality (the "grandiose self Kohut also proposes that, in addition to mirroring, the child needs the opportunity to idealize the parents and draw strength from this borrowed sense of importance. When parents either are truly not admirable or their weaknesses are prematurely or shockingly revealed to the child, the hunger for powerful figures goes unsatisfied and becomes a persistent feature of later, adult life. It is this paradoxical mixture of grandiosity and hunger to belong to prestigious others that forms the nucleus of narcissistic character. Inner fragility of self-esteem is hidden
274
Narcissistic Personality Disorder
by these compensatory structures. Any threat to such self-regulation mobilizes shameful sense of imperfection and intense, vengeful anger ("narcissistic rage"). In contrast to Kohut, Kernberg regards narcissistic personality not as a developmental arrest but a specific pathological formation to begin with. Kernberg differentiates the normal narcissism of children (which retains a realistic quality and does not affect the capacity for mutuality) from the early development of pathological narcissism (which creates fantastically grandiose fantasies and impairs the capacity for mutuality). Kernberg agrees that narcissistic individuals were treated by their parents in a cold, even spiteful manner. However, he adds that they were also viewed as special since they possessed some outstanding attribute, e.g., talent, beauty, superior intelligence, etc. Using Kohut's term with a different formulation, Kernberg proposes that "grandiose self" is formed by the fusion of a highly idealized view of oneself (built around some truly good aspect of oneself) and a fantastically indulgent and admiring inner audience of imagined others. Such grandiose self is a defensive structure against the anger directed at the frustrating parents of childhood. Rage in narcissistic personality is therefore the inciting agent, not merely an epiphenomenon. The views of Kohut and Kernberg differ in many other ways but their most important differences involve (i) a developmental arrest versus a pathological formation view of grandiosity, and (ii) the reactive versus the fundamental view of aggression in narcissistic personality disorder. These differences affect the techniques which the two theoreticians propose as being suitable to treat this condition.
IV. TREATMENT The treatment of choice for narcissistic personality disorder is psychoanalysis, provided the patient is psychologically minded, has verbal facility, and is earnestly motivated for change. Within the psychoanalytic framework, however, the approaches outlined by Kohut and Kernberg (and developed further by their proponents) differ considerably. Kohut's approach aims at a full-blown reactivation, in vivo, of the frustrated childhood mirroring and idealizing needs. The analyst accepts the validity of such needs and helps
the patient see their persistence as emanating from childhood deprivations. The patient's rage, if it erupts in treatment, is interpreted as an understandable response to the inevitable empathic failures of the analyst. Such an experience is then shown to have connections with similar experiences caused by faulty parental empathy during childhood. Countless repetitions of feeling understood and seeing the present in the light of past gradually facilitate the relinquishment of grandiosity and idealizations. Kernberg's approach differs. He emphasizes that the experiences of narcissistic patients in analysis are not readily traceable to the actuality of their childhoods. Instead, these are multilayered and include in them early wishes, defenses against those wishes, real experiences, and unconscious distortions of them. Kernberg notes that the patient's disappointments in the analyst not only reveal his or her real or fantasied frustrations of childhood, now being repeated in the treatment situation, but also dramatically reveal the patient's psychic readiness for hate and total devaluation of others. Kernberg does not view the patient's rage as a reaction to the analyst's failures but as an inevitable manifestation of the patient's pathology. At its core, this involves seething rage against real and imagined hurts from parents, a rage that is also used defensively to ward-off dependent longings. Empathy, for Kernberg, is not a therapeutic measure but a technical necessity. The mainstay of treatment is working through the patient's rage and mistrust, anxiety about dependence, and, in later phases of treatment, the guilt over having exploited, devalued, and hurt others including the analyst. With diminution of rage and dread of true attachment, there emerges a capacity to empathize with others, a reduction in self-centeredness, an ability to give, and a dawning awareness of life's complex emotional offerings in the context of genuine affective involvement with fellow human beings. This article has been reprinted from the Encyclopedia of Human Behavior, Volume 3.
BIBLIOGRAPHY Akhtar, S. (1992). "Broken Structures: Severe Personality Disorders and Their Treatment." Jason Aronson, Northvale, NJ. Akhtar, S. (1989). Narcissistic personality disorder: Descriptive features
Narcissistic Personality Disorder
and differential diagnosis. Psychiatric Clinics of North America 12,505-529. Bach, S. (1977). On the narcissistic state of consciousness. In "Narcissistic States and the Therapeutic Process." Jason Aronson, New York. Kernberg, O. F. (1975). "Borderline Conditions and Pathological Narcissism." Jason Aronson, New York. Kernberg, O. F. (Ed.) (1989). Narcissistic personality disorder. The
Psychiatric Clinics of North America, xii (3). Kohut, H. (1971). "The Analysis of the Self." International Universities Press, New York.
275
Kohut, H. (1977). "The Restoration of the Self." International Universities Press, New York. Mahler, M. S., & Kaplan, L. (1977). Developmental aspects in the assessment of narcissistic and so-called borderline personalities. In "Borderline Personality Disorders: (P. Hartocolis, Ed). International Universities Press, New York. Modell, A. (1984). "Psychoanalysis in a New Context." International Universities Press, New York. Volkan, V. D. (1982). Narcissistic personality disorder. In "Clinical Problems in Psychiatry" (J. O. Cavenar, and H. K. H. Brodie, Eds.). Lippincott, Philadelphia, PA.
JeffersonMedicalCollege
I. II. III. IV.
Manifestations Distinction from Related Conditions Intrinsic Nature Treatment
beginning with Sigmund Freud's elucidation of the concept of narcissism. Freud published his seminal paper "On Narcissism" in 1914. He defined narcissism as the concentration of libidinal interest upon one's ego and distinguished primary from secondary narcissism. The former was a normal phenomenon of infancy, the latter a result of withdrawal of interest from the outer world. Freud noted that human attachments are of two types: anaclitic and narcissistic. The former are evident when we are involved with those who nourish and protect us and the latter when we are involved with those who merely reflect us (the way we are, or were, or will be). In essence, the narcissistic relationship is nothing but thinly veiled sell-affirmation. While avoiding character typology in this paper, Freud did refer to individuals who compel our interest by the narcissistic consistency with which they manage to keep away from their ego anything that would diminish it." However, it was not until 1931 that he described the "narcissistic character type."
Narcissism Emotional investment into the self. When normal, it leads to sustained self-regard and mature aspirations. When pathological, it is accompanied by inordinate demands upon the self, excessive dependence upon acclaim from others, and deteriorated capacity for interpersonal relations. Personality Disorder A pervasive pattern of chronically maladaptive behavior which is a source of constant interpersonal problems. Personality disorders are ego-syntonic, i.e., such individuals are not aware of their own personalities as being deviant or abnormal. They suffer from the interpersonal consequences of their behavior but they do not recognize their own role in the origin and perpetuation of these problems. Such individuals are therefore unlikely to seek professional advice although they may consent to it if this is urged by others or forced by social repercussions of their behavior.
The subject's main interest is directed to self-preservation:he is independent and not open to intimidation. His ego has a large amount of aggressiveness at its disposal, which also manifests itself in readiness for activity. In his erotic life loving is preferred above being loved. People belongingto this type impress others as being "personalities"; they are especially suited to act as a support for others, to take on the role of leaders and to give a fresh stimulus to cultural development or to damage the established state of affairs.
NARCISSISTIC PERSONALITY DISORDER is a newly recognized diagnostic entity in clinical psychiatry. It was introduced into "official" psychiatric nomenclature in 1980 with the publication of the third edition of the American Psychiatric Association's Di-
This description is generally viewed as the pioneering portrayal of narcissistic personality disorder. The fact, however, is that a 1913 paper by Ernest Jones, one of Freud's distinguished pupils, also contained signi-
agnostic and Statistical Manual of Mental Disorders (DSM-III). There is, however, evidence that the concept had been evolving since the turn of the century
271
Copyright 9 1998 by Academic Press. All rights of reproduction in any form reserved.
272
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Narcissistic Personality Disorder
ficant details regarding the phenomenology of this condition. Using the term "God Complex" for their condition, Jones portrayed such individuals as excessively admiring of themselves, having omnipotent fantasies, being exhibitionistic, and scornful of others. Such grandiosity is, at times, masked by caricatured modesty, pseudohumility, and a pretended contempt for materialistic aspects of life. Over the subsequent decades, many other psychoanalysts contributed to the study of narcissistic personality. Prominent among these were Robert Waelder, Wilhem Reich, Christine Olden, Helen Tartakoff, and John Nemiah. These authors clearly recognized this condition though often without designating it as such. They noted that the central feature of this condition, grandiosity, is a defensive maneuver against feelings of inferiority which they traced to severe frustrations during early childhood. In the 1970s the publication of two psychoanalytic books breathed new life in the study of narcissistic personality disorder: The Analysis of the Self (1971) by Heinz Kohut and Borderline Conditions and Pathological Narcissism (1975) by Otto Kernberg. The views of Kohut and Kernberg are summarized below. Suffice it to say here that their works stirred up considerable controversy and mobilized further interest in investigating the true nature of narcissistic personality disorder. Among those who made subsequent major contributions are Sheldon Bach, Ben Bursten, Mardi Horowitz, Arnold Modell, Arnold Rothstein, and Vamik Volkan. Finally, when in 1980 the DSM-III included narcissistic personality disorder as a separate diagnostic entity, an official imprimatur was added to the evolving concept. The DSM-IV retained the condition with only minor modifications of its diagnostic criteria.
I. MANIFESTATIONS
The cardinal feature of narcissistic personality disorder is heightened narcissism. Individuals with this disorder display grandiosity, intense ambition, and an insatiable craving for admiration. Their consuming self-interest renders them incapable of appreciating and understanding the independent motivations and needs of others. Consequently, they come across as cold, unempathic, exploitative, and having little concern for those around them.
The clinical features of narcissistic personality disorder involve six areas of psychosocial functioning: (i) self-concept, (ii) interpersonal relations, (iii) social adaptation, (iv) ethics, standards, and ideals, (v) love and sexuality, and (vi) cognitive style. In each of these areas there are "overt" and "covert" manifestations. These designations do not necessarily imply their conscious or unconscious existence although such topographical distribution might also exist. In general, however, the "overt" and "covert" designations denote seemingly contradictory phenomenological aspects that are more or less easily discernible. Moreover, these contradictions are not restricted to the individual's self-concept but permeate his interpersonal relations, social adaptation, love life, morality, and cognitive style. Narcissistic individuals have a grandiose selfconcept. They give an appearance of self-sufficiency and are preoccupied with achieving outstanding success. Covertly, however, they are fragile, vulnerable to shame, sensitive to criticism, and filled with morose self-doubts and feelings of inferiority. Their interpersonal relations are extensive but exploitative and driven by an intense need for tribute from others. They are unable to genuinely participate in group activities and, in family life, value children over the spouse. Inwardly, they are deeply envious of others' capacity for meaningful engagement with life. They attempt to hide such envy by scorn for others; this may, in turn, be masked by pseudo-humility. Capable of consistent hard work, narcissistic individuals often achieve professional success and high levels of social adaptation. However, they are preoccupied with appearances and their work is done mainly to seek admiration. The overly zealous vocational commitment masks a dilettante-like attitude, chronic boredom, and gnawing aimlessness. Their ethics, standards, and ideals display an apparent enthusiasm for sociopolitical affairs, a caricatured modesty, and pretended contempt for money in real life. At the same time, they are often quite materialistic, ready to shift values to gain favor, irreverent toward authority, and prone to pathologic lying and cutting ethical comers. A similar contradiction is evident in the realm of love and sexuality. Overtly, narcissistic individuals are charming, seductive, and given to extramarital affairs, even promiscuity. Covertly, however, they draw little gratification beyond physical pleasure from sexuality
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
273
Narcissistic Personality Disorder
and are unable to have deep and sustained romantic relations. Moreover, they seem unable to genuinely accept the incest taboo and are vulnerable to sexual perversions. Superficially, their cognitive style suggests a decisive, opinionated, and strikingly supple intellect. However, their knowledge is often limited to trivia ("headline intelligence") and they are forgetful of details. Their capacity for learning is also compromised since learning forces one to acknowledge one's ignorance and they find this unacceptable. They are articulate but tend to use language and speaking for regulating self-esteem rather than communicating. In sum, narcissistic personality disorder is characterized by a defensively inflated self-concept which is fueled by fantasies of glory, protected by being constantly admired for social success, and buttressed by scornful devaluation of those who stir up envy. Underneath this grandiose self-concept (not infrequently built around some real talent or special aptitude) lie disturbing feelings of inferiority, self-doubt, boredom, alienation, and aimlessness.
tal states. They are less tolerant of aloneness, more angry, and have a poorer capacity for sustained work than narcissistic individuals. [See BORDERLINE PERSONALITYDISORDER.] Both antisocial and narcissistic individuals dream of glory and can lie, cheat, and indulge in ethically dubious acts to achieve success. However, in narcissistic personality such disregard of conventional morality is hidden, occasional, and cautious whereas in antisocial personality it is open, frequent, ruthless and calculated. [See ANTISOCIALPERSONALITYDISORDER.] Both paranoid and narcissistic individuals are grandiose, emotionally stilted, envious, sensitive to criticism, and highly entitled. However, the paranoid individual is pervasively mistrustful and lacks the attention-seeking charm and seductiveness of the narcissist. The cognitive style of the two types of individuals differs in a striking way. The narcissist is inattentive to real events and forgetful of details. The paranoid, in contrast, has a biased but acutely vigilant cognition. [See PARANOIA.]
III. INTRINSIC NATURE II. DISTINCTION FROM RELATED CONDITIONS Individuals with narcissistic personality disorder have superficial resemblances to those with compulsive personality disorder. Both types of individuals display high ideals, great need for control, perfectionism, and a driven quality to their work. However, the compulsive seeks perfection while the narcissistic claims it. Consequently, the compulsive is modest, the narcissist haughty. The compulsive loves details that the narcissist casually disregards. The compulsive has a high regard for authority and strict inner morality, while the narcissist is often rebellious and prone to cutting ethical corners. [See OBSESSIVE--CoMPULSIVE
DISORDER.] Three other characterological constellations need to be distinguished from narcissistic personality disorder: borderline, antisocial, and paranoid personality disorders. Both borderline and narcissistic individuals are self-absorbed and vacillating in their relationships. Borderline individuals, however, show a greater propensity for disorganization into really regressed men-
In the realm of probable causes and the intrinsic nature of narcissistic personality disorder the views of Heinz Kohut and Otto Kernberg form the two major, if sharply divergent, contemporary perspectives. According to Kohut, the origin of narcissistic personality disorder resides in faulty parental empathy with the child. Kohut posits that a growing child needs an enthusiastically responsive audience ("mirroring") for his or her activities and achievements. When such mirroring is deficient, the child's ordinary pride and associated healthy need to be affirmed take on an insistent and unhealthy exhibitionistic quality (the "grandiose self Kohut also proposes that, in addition to mirroring, the child needs the opportunity to idealize the parents and draw strength from this borrowed sense of importance. When parents either are truly not admirable or their weaknesses are prematurely or shockingly revealed to the child, the hunger for powerful figures goes unsatisfied and becomes a persistent feature of later, adult life. It is this paradoxical mixture of grandiosity and hunger to belong to prestigious others that forms the nucleus of narcissistic character. Inner fragility of self-esteem is hidden
274
Narcissistic Personality Disorder
by these compensatory structures. Any threat to such self-regulation mobilizes shameful sense of imperfection and intense, vengeful anger ("narcissistic rage"). In contrast to Kohut, Kernberg regards narcissistic personality not as a developmental arrest but a specific pathological formation to begin with. Kernberg differentiates the normal narcissism of children (which retains a realistic quality and does not affect the capacity for mutuality) from the early development of pathological narcissism (which creates fantastically grandiose fantasies and impairs the capacity for mutuality). Kernberg agrees that narcissistic individuals were treated by their parents in a cold, even spiteful manner. However, he adds that they were also viewed as special since they possessed some outstanding attribute, e.g., talent, beauty, superior intelligence, etc. Using Kohut's term with a different formulation, Kernberg proposes that "grandiose self" is formed by the fusion of a highly idealized view of oneself (built around some truly good aspect of oneself) and a fantastically indulgent and admiring inner audience of imagined others. Such grandiose self is a defensive structure against the anger directed at the frustrating parents of childhood. Rage in narcissistic personality is therefore the inciting agent, not merely an epiphenomenon. The views of Kohut and Kernberg differ in many other ways but their most important differences involve (i) a developmental arrest versus a pathological formation view of grandiosity, and (ii) the reactive versus the fundamental view of aggression in narcissistic personality disorder. These differences affect the techniques which the two theoreticians propose as being suitable to treat this condition.
IV. TREATMENT The treatment of choice for narcissistic personality disorder is psychoanalysis, provided the patient is psychologically minded, has verbal facility, and is earnestly motivated for change. Within the psychoanalytic framework, however, the approaches outlined by Kohut and Kernberg (and developed further by their proponents) differ considerably. Kohut's approach aims at a full-blown reactivation, in vivo, of the frustrated childhood mirroring and idealizing needs. The analyst accepts the validity of such needs and helps
the patient see their persistence as emanating from childhood deprivations. The patient's rage, if it erupts in treatment, is interpreted as an understandable response to the inevitable empathic failures of the analyst. Such an experience is then shown to have connections with similar experiences caused by faulty parental empathy during childhood. Countless repetitions of feeling understood and seeing the present in the light of past gradually facilitate the relinquishment of grandiosity and idealizations. Kernberg's approach differs. He emphasizes that the experiences of narcissistic patients in analysis are not readily traceable to the actuality of their childhoods. Instead, these are multilayered and include in them early wishes, defenses against those wishes, real experiences, and unconscious distortions of them. Kernberg notes that the patient's disappointments in the analyst not only reveal his or her real or fantasied frustrations of childhood, now being repeated in the treatment situation, but also dramatically reveal the patient's psychic readiness for hate and total devaluation of others. Kernberg does not view the patient's rage as a reaction to the analyst's failures but as an inevitable manifestation of the patient's pathology. At its core, this involves seething rage against real and imagined hurts from parents, a rage that is also used defensively to ward-off dependent longings. Empathy, for Kernberg, is not a therapeutic measure but a technical necessity. The mainstay of treatment is working through the patient's rage and mistrust, anxiety about dependence, and, in later phases of treatment, the guilt over having exploited, devalued, and hurt others including the analyst. With diminution of rage and dread of true attachment, there emerges a capacity to empathize with others, a reduction in self-centeredness, an ability to give, and a dawning awareness of life's complex emotional offerings in the context of genuine affective involvement with fellow human beings. This article has been reprinted from the Encyclopedia of Human Behavior, Volume 3.
BIBLIOGRAPHY Akhtar, S. (1992). "Broken Structures: Severe Personality Disorders and Their Treatment." Jason Aronson, Northvale, NJ. Akhtar, S. (1989). Narcissistic personality disorder: Descriptive features
Narcissistic Personality Disorder
and differential diagnosis. Psychiatric Clinics of North America 12,505-529. Bach, S. (1977). On the narcissistic state of consciousness. In "Narcissistic States and the Therapeutic Process." Jason Aronson, New York. Kernberg, O. F. (1975). "Borderline Conditions and Pathological Narcissism." Jason Aronson, New York. Kernberg, O. F. (Ed.) (1989). Narcissistic personality disorder. The
Psychiatric Clinics of North America, xii (3). Kohut, H. (1971). "The Analysis of the Self." International Universities Press, New York.
275
Kohut, H. (1977). "The Restoration of the Self." International Universities Press, New York. Mahler, M. S., & Kaplan, L. (1977). Developmental aspects in the assessment of narcissistic and so-called borderline personalities. In "Borderline Personality Disorders: (P. Hartocolis, Ed). International Universities Press, New York. Modell, A. (1984). "Psychoanalysis in a New Context." International Universities Press, New York. Volkan, V. D. (1982). Narcissistic personality disorder. In "Clinical Problems in Psychiatry" (J. O. Cavenar, and H. K. H. Brodie, Eds.). Lippincott, Philadelphia, PA.