The many faces of narcissism.

Although the term narcissism is widely used in psychiatric discourse, there is much confusion about its precise meaning. The term is most often used pejoratively to refer to someone with excessive vanity or an urgent need for validation and praise. There is a continuum of narcissism, and the point where healthy self‐esteem ends and pathological narcissism begins is highly arbitrary. A further complication is that some individuals who have elements of pathological narcissism may have sectors of their personalities that are characterized by generosity towards others. It is unfortunate that a false dialectic between narcissism and altruism is in common usage. The two entities regularly co‐exist. Vaillant1, in his longitudinal study of healthy males, found that altruism increases significantly in the second half of life – not simply because we become more selfless as we age, but rather because helping others becomes more rewarding to us. A neuroimaging study2 demonstrated that those who are altruistic directly benefit from their altruism. Participants had to choose to endorse or oppose societal causes by anonymous decisions to donate or refrain from donating to real charitable organizations. The mesolimbic reward system was engaged when one donated money in the same way as it was when one received monetary awards. In other words, altruism activates brain centers that are associated with selfish pleasures like sex or eating. A further complication is that the term narcissism is used as a clinical entity as well as a way of denoting cultural trends, as in C. Lasch's book The Culture of Narcissism 3, describing a cultural phenomenon in the 1970s in which the growing role of the media promoted a lack of substance and depth in the culture. In our decade, we are in the midst of another cultural awakening as the constant interaction with technology and social media is impacting the cultural perspective of the self. Members of the millennial generation live in a constantly connected, technologically visible, self‐oriented public space. Time captured this cultural moment by referring to the “Me Me Me Generation”. S. Turkle4 described how the smartphone generation is populated by people who are losing the art of human interaction. A radical new self is emerging, one that is shaped by what we want others to see. One can receive validation, praise and self‐esteem enhancement within seconds after pressing “send” or posting a “selfie”. In a study by Stinson et al5, there were nearly three times the number of persons in their twenties meeting criteria for narcissistic personality disorder than in the age group over 65. However, we must question the idea that the current generation is developing such a vastly higher number of narcissists. The overlap between cultural shifts and individual pathology must be more complex than simply following a list of diagnostic criteria. Moreover, the constant connection to social media has also led to altruism in this new generation. Indeed, they are dedicated to service projects, are socially aware and contribute to charity at a higher rate than their elders6. Not only do we need to consider the false dialectic between narcissism and altruism in individuals; we must also consider it more broadly in the culture. In the midst of this confusion, how do we distinguish healthy self‐interest from pathological narcissism, usually referred to as narcissistic personality disorder? The time‐honored indices of “to love and to work” are problematic in this context, because some of the most successful individuals from an economic perspective are also highly narcissistic7. Their narcissistic need for acclaim and recognition may motivate them to succeed. On the other hand, the capacity for mutuality and reciprocity in love relationships may be useful in identifying narcissistic personality disorder. Others are often used up and discarded, existing only to serve the narcissistic individual's needs. While problems in human relatedness are central to narcissistic personality disorder, clinicians must be alert to the fact that narcissistic individuals may have considerable variability in their ways of relating to others. There is a spectrum of narcissistic personality disorder, not necessarily reflected in the official nomenclature. Psychoanalytic debates about narcissistic patients stemmed from differences noted by Kohut8 and Kernberg9. While Kohut's formulation was based on a self‐deficit model, causing patients to be highly sensitive to narcissistic injury, Kernberg emphasized the aggressive and destructive aspects of these patients. Further research has documented the existence of two subtypes of narcissistic personality disorder: the grandiose and oblivious variant and the hypervigilant or fragile subtype7. More recent research10 detected a further high‐functioning variant, which is outgoing, energetic and articulate, with an exaggerated sense of self‐importance. The fact that narcissistic personality disorder is not a monolithic entity creates challenges for the diagnostician and the psychotherapist. In keeping with the notion that the key to diagnosis lies in the quality of love relationships, we suggest that a careful examination of modes of relatedness is crucial7. As Kohut stressed, some patients who are narcissistically organized tend to idealize others so that they can bask in the reflected glory of an idealized object. They may insist on the most famous psychotherapist or pick a romantic partner purely on his/her looks so that others will be impressed. Denial of the romantic partner's autonomy may be a central strategy for some narcissists. They are wounded if their love object acts or thinks independently. The fantasy of control serves to defend against ongoing anxiety of losing the one they love. However, it also represents a common problem with narcissistic individuals – namely, they cannot mentalize the internal experience of the other. Hence, they are unable to empathize with the partner's need for agency, autonomy, and freedom from control. Another common mode of relatedness is to deny all pain or conflict in the love relationship, thus turning away from reality. Narcissistic patients are desperately attempting to manage their vulnerability. Hence denial of dependency, sometimes referred to as “pseudo‐self‐sufficiency”, is another strategy in their repertoire. If they do not need anyone, then they cannot be hurt by losing someone. Another way that narcissistic individuals will relate to love objects is to see the other as completing the self. It is as though there is a “hole” in their sense of self that requires another person to perform missing functions for them. A common form of this occurs in patients who cannot soothe themselves and need their romantic partner to comfort them, tell them they are wonderful, and provide empathy for their pain. The relationship may end when the partner is not consistently providing the admiration or praise the patient requires. Narcissism is pervasive in its normal and pathological variants. While some presentations are quickly apparent in treatment, as in the oblivious subtype, others may take longer to manifest in the clinical relationship. A person with the high functioning variant, who presents with energy, gregariousness and self‐importance, may be initially charming to the psychiatrist and hence it takes longer to detect clinically significant narcissism. Only over time does the lack of relatedness and low self‐esteem become clear. Narcissistic patients may feel understood if the clinician focuses on self‐esteem struggles and vulnerability beneath the grandiose surface. Some patients may not be able to tolerate any confrontation at first, and may need long periods of empathic validation in order to preserve a therapeutic alliance. A subset of these hypervigilant patients may never be able to tolerate confrontation or rupture, and may instead use the treatment over months and years to shore up a shaky sense of self‐esteem and build validation. Timing is everything in making an impact through interventions, and it is advisable to wait for openings in which the patient lets the therapist know that he or she is hurting and yearning for help. The psychiatrist must be attentive to countertransference issues. Kernberg9 described that the therapist can feel consigned to a “satellite existence”, which can lead to boredom and distance impacting the therapy. In addition, therapists must be alert to contempt and enactments of judgment and criticism. Finally, patients with narcissistic problems can require some of the longest treatments in a therapist's caseload. Consultation is recommended in conflicted or difficult cases. Glen O. Gabbard, Holly Crisp‐Han Department of Psychiatry, Baylor College of Medicine, Houston, TX, USA