Narcisism vs. Stima de Sine Da

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HARVARD MEDICAL SCHOOL

Harvard Menta l Heal th Let teV O L U M E 2 0 NUMBER 8 FEBRUARY 20Narcissism and self-esteem

Psychotherapists try to discourage one, encourage th e other, and understand how INSIDEthe two are related.T he mythical Narcissus rejected alllovers, the n fell in love with h is ownreflection in a forest pool. The psy-chiatric definition of narcissistic personalityincludes many destructive forms of self-love not only v an ity but self-impor-tance, self-absorption, self-centeredness,a n d apatronizing or contemptuous at t i-tude toward others. I t is a problem in i tsown right and a complication in the t reat-ment of many psychiatric disorders. Butnarcissism is also related to self-esteem,which psychotherapists usually regard asva luable and wan t to encourage. So itbecomes especially important to distin-guish narcissism from self-esteem andrela ted t ra i ts self-liking, self-accept-ance, and self-confidence.As described inthe American Psychi-atric Association's diagnostic manual, nar-cissistic personality disorder is character-ized by feelings of superiority and a senseof entitlement. Narcissistic personalitiesn e e d tofeel unique. They rely upon anunrealistic view of t h e i r t a l e n t s andprospects, and may dream of unlimitedfame and power and ideal love. In theireyes, their problems and needs, l ike theirgifts, are ext raord inary a nd deserve priori-

ty. T h e y d e m a n d a t t e n t io n a n d a d m i r a t io nand expect special favors as a right.Narcissistic personalities pay Httle a t t e n -tion to other people's feelings and wishes.They ar e in terested in othe rs mainly as mir-rors in which they can admire their ownfeatures th e pool of Na rcissus or asi n s t r u m e n t s for satisfying their wants.They freely take advantage of others andexpect grati tude in return. The other sideof the ir arrogan ce is envy. They ten d to beboth envious and contemptuous of others.

especial ly those they regard as their rivals,while openly conveying a belief th at othersenvy them .Like othe r personali ty disorders, narcis-sistic personality rarely occurs in pureform. It 's one of a group of disorders thatalso includes borderline, antisocial , andhistrionic pe rsona lities. Two-thirds of peo-ple diagnosed with narcissistic personalitydisorder also qualify for one of these diag-noses, part ly because th ey involve man y ofthe same trai ts. Histrionic personali ty ischaracterized by a craving for at tentionand admiration; antisocial personali ty byarrogance and disregard for the feelings ofother s; an d borde rline persona li ty by em o-tional volatility, especially when importantrelationships become disappointing.Although i t 's not part of the AmericanPsychiatric Association's definition, mostmental heal th professionals believe thatthe self-love of narcissistic personalities isprecarious and easily threatened. They canavoid a cknowledging failure by setting lowstandards that are easily met if at firstyou d on' t succeed, act as though you ne vertried. When nothing else works, they mayblame their fai lures on others. They re-quire , expect , and demand cons tan t sup-port for the ir high opinions of themselves,

so they feel surprised and betrayed whenthey are criticized or rebuffed in any way.Then, to maintain the image of themselvesas superior, they may lash out in an angrycounterat tack.They may also react to asetback withshame. Some psychiatric clinicians believethere are narcissistic personali t ies who donot show the obvious signs detai led in thed iagnost ic manual . They don ' t open lyclaim superiority or a right to special treat-

Recovering fromschizophreniaThere is no cure, but manypeople with this disordercope surprisingly well in thelong run 4In br iefLifesaving lithium : Newresearch favors an old drug . . . 7Reliving traum a: It is effectivefor some, but too manydrop out 7Q & A :Are there any good drugtreatments for binge eatingdisorder? 8

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Narc iss ism continuedment. They may even seem superfi-cially modest, anxious, and dissatis-fied with themselves. B ut these "vul-nerable" narcissists harbor a secreta r rogance . They are argumenta t ivea n d d e m a n d i n g and sometimesexplode in anger, which is followedby shame and depression. To avoidreject ion tha t would damage theirself-esteem, they may become sosocial ly withdrawn tha t they resem-ble avoidant personal i t ies.

Looked at this way, narcissismmust eventual ly lead to disappoint-m e n t , and the question is w h e t h e r aperson wil l respond to the disap-p o i n t m e n t by fee l ing ashamed andwithdrawing, or by angri ly reasser t-ing superiori ty. Either way, it isunheal thy. Narcissus drowned whenhe t r i ed to embrace his reflection.P s y c h o a n a l y t ic v ie w sThe idea of narcissism comes to psy-chia t ry through the psychoanalytict r a d i t i o n , and it was e l a b o r a t e dmostly by two psychoanalysts. OttoKernberg and Heinz Kohut. Bothemphasized the vulne rabi l i ty t ha tund erl ies na rcissist ic a rrogance , butthey disagreed about the deve lop-m e n t and t r e a t m e n t of narcissisticpersonality. Describing their ideasrequires some specialized languagethat may seem forbidding.According to Kernberg, our child-hood inne r worlds con ta in r epresen-t a t ions or images of people who areemotionally significant, especiallyourselves and our paren ts . These"objects" and our relationships witht h e m are the keys to an u n d e r s t a n d -in g of narcissism. Kernberg believesthat narcissistic personality is a re-sponse to coldness, indifference, orhidden aggression on the p a r t ofp a r e n t s who, without being t rulyaffectionate, try to convince a childof his or her own i m p o r t a n c e .Narcissistic personalities live in fearof these persistent inte rn al images ofp a r e n t s to which they a t t r ibute their

own ange r at the t r e a t m e n t t h e yreceived in childhood. They fee l tha tt hey cannot be loved unless they areperfect. Their internal objects, repre-sen t a t ions t ha t r emain in the m i n d ,are n ever assimila ted and in t egra t ed ,and t he i r ad u l t r e l a t ionships are dis-tor ted . They cann ot distinguish th eirreal abilities from gran diose fantasiesor live up to the internal image of anideal parent. Their superficial self-sufficiency is belied by t he i r envyand c raving for admira t ion .

This implicit self-image of thenarcissist ic personal i ty provides adefense for the ego an u n c o n -scious way of coping with the stressof internal confl ict . The defensesused by narcissistic personalities areimmature , invo lv ing a d e n i a l ofresponsibility for t he i r own feelingsand act ions. These defenses includeprojection attributing one's feel-ings to o t h e r s in o r d e r to avoidacknowledging them a n d i d e a l -ization of, or contempt for, others.Narcissistic personalities make eventhose the y ideal ize into poten t ia l en e-mies, because the y project on to the seidealized figure s, who are also rivals,their own wish to exploit othe rs.

Kohut re gards na rcissism in a wayt h a t is similar, yet different. H is viewis tha tfi-omear ly chi ldhood on we allhav e "selfobjects," inte rna lized repr e-senta t ions of people (mainly par en ts)who maintain the sense of a self byreflecting a child 's wishe s for re cogni-tion and praise a process calledmir ror in g. Selfobjects are also repre-sentative of a child's need to idealize,and t hey se rve as models, creating asense of what Kohut calls "twinship"between child andp a r e n t . As a n a t u -ral stage of development , we all star tout vth this "grand iose self" and anidealized image of our pa re n ts . W ithgood parent ing, these primal narcis-sistic selfobjects are modera t ed andbecome the basis for a mature per-sonality.

Kohut bel ieved tha t theparen ts ofHARVARD iVIENTAL HEALTH LETTER www,heaith,harvard,edu FEBRUARY 2004


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narcissistic personalities are capriciousand unreliable, reject the child, or treatthe child as an extension of themselves.The child grows up with a distortedview of what it means to be lovable. Todefend themselves (unconsciously)against feeling imlovable, narcissisticpersonalities imagine themselves asperfectly lovable a self-image theyneed in o rder to receive the adm irationnot supplied by their parents. Theyview themselves as having no needsthey cannot provide for themselves.But because no one is self-sufficient,this belief only leads them to becomevulnerable to disappointment. Theirunderlying feelings of worthlessnessand emptiness force them into a con-stant search for recognition. They enterrelationships expecting others to grati-f y a l l their unconscious wishes. They donot develop either rational self-esteemor a sense of responsibility and empa-thy for others.

Mental health professionals whotreat narcissistic personalities usuallysay that these patients seek therapymainly when they can no longer sus-

Groopman LC, et al. "NarcissisticPersonaiity Disorder," in Gabbard GO ,e d . . Treatments of PsychiatricDisorders, Second Edition, AmericanPsychiatric Press, 1995,Kernberg OF. Borderline Conditionsan d Pathological Narcissism. JasonAronson, 1995,Kohut H. Analysis of Self, inter-nationai Universities Press, 2000.Kraus G, et al. 'Tii e 'A-B-C's' of theCiuster B's: Identifying, Understanding,and Treating C iuster B PersonaiityDisorders," Clinical PsychologyReview (April 2001): V o i , 2 1 , No. 3,p p , 345-73.Mruk C J , ed . Self-Esteem: Research,Theory, an d Practice. Springer,Second Edition, 1999,For more references, piease seewww,health.harvard,edu/mental.

tain their high opinion of themselves.They m ay have lost a job, a lover, or aspouse. Aging or illness may haveundermined their fantasies of superi-ority and invulnerability. This blow toself-love is called narcissistic injury.Psychotherapy cannot radically alternarcissistic personality, but it cansometimes help change thinking andbehavior enough to limit its conse-quences. And understanding narcis-sistic personality can help in choosingtreatments for problems like depres-sion, anxiety, eating disorders, andsubstance abuse.T r e a t m e n t sPeople with narcissistic problems areoften treated with psychodynamic(broadly psychoanalytic) therapy,which works (in part) by uncoveringmechanisms of defense and tracingtheir origins in the emotional con-flicts of early life. An important partof this process is transference there-emergence of childhood feelingsfor parents in the relationship withthe therapist. Here, Kohut concen-trates on a positive transference andKernberg on a negative one.K o h u t ' s a p p r o a c hAccording to Kohut, narcissistic per-sonalities develop three kinds ofresponses, corresponding to theirmental representations of key child-hood relationships. In mirroring thepures t sense of narcissism thetherapist provides a reflection inwhich they can admire themselves. Anarcissistic patient also may identifywith an idealized therapist to gainstrength. Finally, in twinsh ip, the ther-apist becomes an alter ego on whichthey can model themselves.

Kohut believes that in the begin-ning, narcissistic patients need thetherapist as what he calls a primitiveor archaic selfobject the functionserved by parents in early childhood.Therapists should let themselves beused in this way because it creates an

environment in which they can tem-porarily serve as a good parent andallow arrested emotional develop-men t to resume. The therapist shouldallow feelings of mirroring, idealiza-tion, and twinship to develop w ithoutinterpretation or criticism until thetime comes to show their limitations.Once the self has been strengthened,the narcissistic transference can begently challenged so that the psycho-therapist is acknowledged as an inde-pendent person no longer uncon-sciously conceived as identical to thepatient whose limitations are no t abetrayal of trust. This allows thepatient to achieve a form of self-esteem that is not illusory.K e r n b e r g ' s a p p r o a c hKernberg thinks the therapist mu st bemore challenging from the start. Hebelieves that the narcissistic self is notsimply immature but distorted and inneed of correction. The idealizingtransference and the underlying envyand contempt must be confrontedimmediately and interpreted as aresult ofthe patient's yearning for lov-ing care from a parent. Kernbergtreats idealization as a defense againstfear of attack from a therapist towhom the patient has attributed hisown anger.

Psychoanalysis and psychodynam-ic therapy also require an analysis ofthe countertransference the feel-ings of the therapist for the patient,which reflect both the patient's andthe therapist's unconscious em otionalconflicts. Narcissistic patients can bedifficult to treat. Ungrateful, dismis-sive, demanding special treatment, theycan make psychotherapists uncom-fortable, angry, or ashamed of theirlimitations and defects. Psychothera-pists may begin to feel ineffectual andincompetent, or on the contrary, maybecome too fond of being idealized.The therapist must recognize thesefeelings, put them in context, and usethem to better understand the pa tient.

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o t h e r t h e r a p ie sIf the patient is seeking help becauseof a marital crisis, couples therapycan be added to individual treatment.Group therapy is another possibility.Narcissistic patients create difficultiesbecause of their hunger for admira-tion, their envy, and their willingnessto take advantage of others. There's adanger that they will simply be givenfree rein to talk about themselves. Butgroups also offer an opportunity toconfront their behavior safely andexpose underlying needs and feelings.At the same time, they can see howtheir behavior affects others and maybecome genuinely involved with theproblems of other people for the firsttime.T h e s e l f- e s te e m p a r a d o xThe psychodynamic way of thinkingabout narcissism and its treatmentraises the question of when self-loveis justified and reasonable. A s psycho-analysts recognize, narcissistic needsand vulnerability are normal. Mostpeople want to like themselves, provethemselves, and be proud of them-selves. They can be competitive, andthey are capable of feeling envy andshame. Recognizing one's own virtuesand talents isdesirable. Thinking wellof yourself is good for you; for exam-p l e , it's been shown to be associatedwith- quicker physiological recoveryfrom stress, as measured by levels ofstress hormones. The philosopherAristotle wrote that the "magnani-mous" person who demands andreceives deserved honors represents avirtuous golden mean between thosewho claim too much and those whoclaim too little for themselves.

It would be easy to say that narcis-sism is illusory or defensive a s opposedto genuine self-esteem. But studiesshow that even illusory self-esteem isgood for mental health and personalrelations. In psychological experi-ments, people with high but healthyself-esteem take more credit for suc-

cess than they deserve and less blamefor failure. And even those whom oth-ers like most nevertheless have opti-mistic illusions about how much theyare liked. According to some studies,depressed people are actually morerealistic about themselves, theirprospects, and the way others regardthem sadder but wiser.

It seems paradoxical to say that aperson with limited self-knowledge isable to act well and function effective-ly. The distinction between self-esteem and narcissism seems to disap-pear. One way to think about this par-adox is to say that having too good anopinion of yourself in a vague andgeneral way is compatible with rea-sonably acknowledging your limita-tions in most real-life situations. Thatis where narcissistic personalities fallshort.Self-esteem is a matter of degree,and the low end of the continuumoften leads to depression or a depres-sive personality. Many psychiatricpatients suffer from low self-esteem,and it can be a vicious cycle. It's easy

to maintain a poor opinion of oneselfbecause others regard pessimism andapathy as evidence of inferiority. Theeffect is to confirm expectations offailure and reinforce self-defeatingattitudes.Low self-esteem can sometimes beraised with cognitive behavioral ther-

a p y , which treats incorrect thinking asa major source of emotional disor-ders. Therapist andpatient reevaluatethe patient's beliefs by restating the mas hypotheses to be tested in action.At least in the short r un, studies showthat this treatment is often effective.But whether raising self-esteemshould be a target of psychotherapy,as opposed to a byproduct of treat-ment for depression andother condi-tions remains controversial. The chal-lenge is to confront grandiose atti-tudes tow ard the self a t the same time.In treating narcissistic personalities,encouraging the right kind of self-love while promoting realistic atti-tudes toward oneself and others is adifficult but worthwhile therapeuticchallenge. W

Recovering from schizophrenia

o HARVARD MENTAL HEALTH LETTER

T he idea that it's possible torecover from schizophreniahas been popularized by thestory of John Nash, as told in thebiography andfilm,ABeautifulMind.The Nobel Prize-winning scientistbegan to suffer delusions andhalluci-nations in his late twenties. He wasdiagnosed as schizophrenic, treatedwith antipsychotic medications, andperiodically admitted to mental hos-pitals for nearly 30 years. The symp-toms gradually faded in his fortiesand fifties; by age 60 he was able tostop taking medications and evenreturn to scientific work.The story may be surprising tosome because a diagnosis of schizo-phrenia is offen thought to imply

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progressive deterioration or, at best,permanent severe disability. One ofthe great early students of the disor-der, Emil Kraepelin, called it demen-tia praecox prem ature deme ntia.But there's plenty of evidence thatNash's case is not unusual, and wemay already know ways to promoterelatively happy outcom es like his.A typical study revealing the possi-bilities included 10 1 patients who wereinterviewed five years affer the diag-nosis. The outcome wasdescribed asgood if they had been working at leasthalf time and had spent less thanthree years in hospitals during theprevious five years, had met withfriends in the prior month, and hadhad only mild or transient psychotic

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Narcisism vs. Stima de Sine Da