Narcissistic Personality Disorders

 

This is the transcription of Otto Kernberg’s lecture on “Narcissistic Personality Disorders”, delivered in Urbino, ltaly, June 6, 1992 under the sponsorship of tbc Psychiatric Service at the Ospedale Civile of Urbino.  The subscquent text is a transcription of a discussion held after the lecture. Special thanks to Dr. Raimondo Venanzini for providing these texts.

 

 

I will attempt to provide an overview of normal and pathological narcissism which includes 1) our definition of narcissism, and 2) a discussion on the narcissistic personality and, in particular, its diagnosis and treatment.  From a practical viewpoint, narcissism has two meanings.  First, within psychoanalytic theory or psychoanalytic metapsychology (meta­psychology is the theoretical aspect of psychoanalysis), narcissism is the libidinal investment of the Self.

Narcissism at that level is in contrast to object libido, which is the investment–the libidinal investment–of others.  At a clinical level narcissism means the regulation of self-esteem.  Normal narcissism is normal self‑esteem regulation;  pathological narcissism is pathological self‑esteem regulation.

Normally our self‑esteem is assured by a number of psychological structures. These include, first of all, an integrated sense of Self;  when we have an integrated sense of Self we have a sense of continuity, cross‑sec­tionally in different circumstances and longitudinally throughout time. That is the first guarantee for normal self‑esteem.

Second, self‑esteem is assured by our internalization of the represen­tation of significant others, what in psychoanalysis is called object‑representation, namely the representations of those who are important to us, whom we love and by whom we feel loved. Their internal representations or images also strengthen the self‑esteem of ourself;  we are surrounded by the friends of our inner world.

Third, our self‑esteem is strengthened by a gratifying expression of our instinctual needs.  When we are able to express, in a satisfactory way, our sexual needs, our aggressive needs, our dependent needs, our self‑esteem increases, while the frustration of these needs decreases it.

Fourth, our self‑esteem is strengthened by our Super‑ego structure;  that is, by our conscious and unconscious internal system of values that are built up gradually throughout childhood and adolescence.

This Super‑ego structure includes two sub‑structures. 1) The ego ideal:  all the ideals to which we aspire. When we live up to these ideals our self‑esteem increases;  when we are unable to live up to them, it decreases.  2) The Super‑ego in a strict sense–the prohibitive aspect of the Super‑ego:  conscious and unconscious self‑criticism.  lf we do not fulfill certain expectations and internalized moral demands, if we feel guilty because of what we are doing, or inferior because of this self‑criticism, our self‑esteem decreases.

The last aspect–and a very important one–that reinforces self-esteem is the success of our relationship with the external environment and the real love and esteem we receive from others–not in our fantasy, but in reality.  Consequently, success in reality and appreciation from others strengthen self‑esteem.

We alI fluctuate in our self‑esteem.  There are times when we feel better about ourselves and times when we feel worse.  But usually, if we essentially live up to our expectations of ourselves;  if we have a relatively satisfactory life with the others;  if we are relatively free to express our needs in a constructive way, our self‑esteem is OK even if, from time to time, we are self‑critical or temporarily depressed.

That completes the definition of normal self‑esteem regulation.  I shall now talk about a first degree of pathological narcissism–a first degree of abnormal self‑esteem regulation, namely that of general neurotic psychopathology–in other words, what happens in symptomatic neurosis and neurotic personality organization.  Neurotic personality disorders include the hysterical personality, the obsessive compulsive personality, the depressive masochistic personality.  In all these cases, there is a normal infantile narcissism fixation.

In normal infantile narcissism there is a fixation to unconscious ethical values of childhood and infancy.  Therefore, the unconscious regulation of self‑esteem by the Super‑ego is carried out in terms of childhood prohibitions that in adulthood should no longer be obeyed.  For example, if a five-year‑old girl believes that she is a valuable person if she is clean and neat and has no sexual behavior, it is perfectly normal.  But if a thirty‑year‑old woman has the same type of unconscious expectations of herself, it is a disaster.  In situations that imply the possibility of sexual life, she may become extremely critical of herself if she has sexual feelings, and may become depressed, or avoid any relationship with a man because sexuality would be a threat.

All kinds of neurotic symptoms are derived from that unconscious fixation on infantile manifestations.  Briefly, this is a non‑specific narcissistic pathology;  non‑specific in the sense that there are many types of neurotic illness that have as a common factor the fixation on normal infantile rather than normal adult values.

This is evident in the psychoanalytical treatment of symptomatic neurosis and character pathology, in that, when the therapist tries to change pathological character traits, or place them in question, the patient feels attacked. Infantile narcissism protects the characterological pathology, and so it becomes a technical problem.

A second, more severe degree of narcissistic pathology, one relatively rare, but interesting because it was the first discovered by Freud, who thus described it pathological narcissism.  In this pathology, a patient projects his Self onto another person, while identifying himself with a person whom he needed in the past.  Typically, Freud described it as present in some cases of male homosexuality in which the male homosexual patient projects his infantile Self onto his object, his homosexual lover, while he himself identifies with his own mother, treating his homosexual partner as he would have wanted to be treated by his mother.

A third degree–and the most severe type of pathological narcissism–is constituted by the narcissistic personality disorder.  Although it was not described by Freud, it is, paradoxically, the most important application of the knowledge about narcissism initiated by Freud, but only discovered, much later, in the combined work of Karl Abraham in Berlin (1919), Joan Rivière in London (1936), Belà Grunberger in Paris in the 195Os, Herbert Rosenfeld in London in the 1960s and 70s, Hans Kohut in Chicago in the 1970s, and my own work as summarized here.

The essential characteristic of the narcissistic personality is the development of the pathological Grandiose Self:  a Self‑concept which is  integrated but abnormal, in contrast to the normal Self‑concept constituted by all the different good and bad aspects of the Self. In contrast to that, the pathological Grandiose Self only integrates ideal aspects of the Self–those real aspects that are compatible with an idealized version of the Self.  It also integrates the ideal aspects of the significant people around us–significant others.  Consequently, pathological Grandiose Self complex is a combination of the ideal aspects of Self and others.  It is an idealized, unrealistic version of the Self that is the central pathology of the narcissistic personality disorder.  All the unacceptable aspects, all the bad aspects of Self, are projected outside and attributed to others, just as the unacceptable aspects of other are also projected outside.

Thus, the pathological Grandiose Self signifies an absorption of everything that is good, and a removal from the internal world of representations, of significant others.  What is good in others is absorbed into the Self; what is bad is projected, so that the pathological Grandiose Self exists in a vacuum.  The internal world does not have the significant representation others that it should have normally.  Some might say that the Grandiose Self does not always have a negative implication.  Kohut’s theory is that the Grandiose Self is originally normal.  But I believe it is always pathological, and the term “pathological Grandiose Self,” rightly or wrongly, signals that pathology.  In addition, the pathological Grandiose Self absorbs those ideal aspects of Self and others that normally constitute the ego‑ideal:  therefore, that patient with pathological narcissism does not have an integrated ego ideal and thus lacks the internal system that reinforces Self esteem.  By the same token, the critical aspects of the Super‑ego tend to be so strong, as they are not neutralized by the ego ideal, that they have difficulty in tolerating this very severe and primitive Super‑ego which creates a tendency to ­project self‑criticism onto others.  The end result is a weakened Super-ego and a tendency to feel criticized by others.

Put differently, the ego ideal is weakened because so much of it is absorbed into the pathological Grandiose Self.  This brings about excessive dominance of the self critical aspect of the Super‑ego, and protect himself against that excessive self‑criticism the patient unconsciously projects it onto others.  This means that he easily feels criticized by others, which weakens his internal Super‑ego even further.

The end result is a severe failure of self‑esteem regulation. Because the Super‑ego is weak, there are no representations of significant others to support self‑esteem. People in reality are devalued, because the unacceptable aspects of self and others are projected onto them, so that the normal self-esteem regulation that comes from the love of others is also weak, resulting ultimately in an essential paradox.  The pathological Grandiose Self means that the individual has a grandiose, but very frail view of himself, because it lacks internal support mechanisms, which causes the individual to become excessively dependent on admiration from others.  But what is the ultimate cause of this pathological development?

We know that the narcissistic personality disorder consolidates between the ages of 5 and 10, and can be diagnosed and treated in childhood. The most important cause is the chronic frustration of the need to be loved and a consequent, inordinate development of rage.  That rage takes the form of envy–namely, envy of the person who is needed, who has what the patient needs but will not give him–love.  Envy is the central effect of the aggressive drive, and is characterized by the wish to destroy that which is envied, to eliminate itself.  Envy, therefore, tends to generate vicious circles, because destroying what is envied reduces even further what one gets.  Normally, when we receive something we feel gratitude.  When frustration and envy are excessive, instead of gratitude, that which is received is being destroyed, leaving in its wake a feeling of emptiness.  As a defense against this vicious circle, narcissistic personalities develop a Grandiose Self, precisely to assure themselves that they have all they need without depending on anyone else.  So the pathological Grandiose Self provides satisfaction, protects against dependency, and against the feared envy in the dependency.  Paradoxically, parents–particularly mothers–who are not able to give their children love, often use

the child narcissistically;  as a source of their own gratification.  The child becomes grandiose in that it satisfies a need of the mother, and this fosters further grandiosity.  In other words, the child learns that it is more important to be admired than loved.

A serious complication of pathological narcissism is the possibility that the same aggression against which the pathological Grandiose Self protects the individual infiltrates the pathological Grandiose Self.  When this happens, one’s ideal sense of Self may include power, cruelty and aggression, which is a particular, extremely severe complication.

Thus far I have had to rely on theory, but from here on the clinical manifestations of the narcissistic personality will appear very logical.  They are 1) manifestations of pathological self love which include excessive self‑reference and self‑centeredness, a sense of grandiosity manifest in exhibitionism, an attitude of Superiority, recklessness, ambitions far exceeding capability, over‑dependency on admiration, shallowness in relations with others because of the devaluative, depreciatory attitude towards others, and a strong oscillation between enormous grandiosity, which when suddenly punctured, leaves strong feelings of inferiority.  There is an oscillation between superiority and inferiority, all of which indicates pathological self‑Iove.

2) A pathological love of others, which includes excessive envy, both conscious and unconscious, of what others have.  This emerges most dramatically in negative therapeutic reaction in treatment, or the patient’s tendency to get worse when he feels that the therapist has something good and valuable to give, because he unconsciously envies the capacity of the therapist to help him–biting the hand that feeds him, as it were.  There is also a tendency to devalue what is received from others, a spoiling of what is received which takes many forms.  One of these is to combine a desperate search for gratification with a deep sense of disappointment when it is obtained as a result of unconscious envy.  This emerges in love relations. Often these patients fall easily in love, idealizing someone of the opposite sex and, as soon as a sexual relationship is formed, devalue the other person, which leads to a narcissistic sexual promiscuity.  At bottom, they envy the other sex.  It is normal for both men and women to experience this envy.  But in these patients it becomes extremely exaggerated, causing endless complications in their sexual life.  They also are exploitative of others, greedy, voracious, and have a tendency to steal the ideas of others.  This becomes apparent in their relationship with the therapist:  they appropriate the ideas of the therapist and feel, when they get better, that it is thanks to their own merits.  They have difficulty in really depending on others, and tend to see others as either fools, enemies or idealized persons whose ideal aspects must be incorporated.  They show a lack of empathy and no capacity for commitment to relations with others.  The most severe cases do not even show the idealization of temporary falling in love, but are totally incapable of falling in love.  This incapacity is typical of narcissistic personalities.  Obviously, this is something which can be evaluated only in late adolescence or in early adulthood.  Their basic Self state is one of emptiness.  They have a feeling of restlessness, of boredom; they need external stimuli to feel “Full” and alive, which predisposes them to drug addiction and alcoholism.  They are unable to remain alone and their habitual sense of emptiness can only be overcome by new sources of admiration.

A third major aspect of their symptoms is Super‑ego pathologies, in which there is a weakening of the Super‑ego.  The symptoms can be classified as relatively mild or very severe cases.  The former show an inability to feel mild sadness or mourning.  They either do not feel sad at all or they feel devastated;  this is because there is no normal Super‑ego regulation. Either they are under attack by a primitive Super‑ego or not at all.  Consequently, they may have severe alternations in mood.  Also, they typically present behavior regulation by shame rather than guilt.  They do not behave in an anti‑social way, more because of possible feelings of shame or being inferior than any guilt feelings or internalized sense of morality.  And their value systems are infantile;  they want to be admired for being the most beautiful, the most powerful, having the most property, rather than for being decent, valuable, committed, creative, intelligent human beings. So their value system–what they need to be admired for–is often childlike.  All of the above are mild manifestations of Super‑ego pathology.

The most severe symptoms of Super‑ego pathology include first of all anti‑social behavior:  stealing, lying, manipulation, cheating, aggressive behavior such as robbery or even assault.  Usually in such cases anti‑social

behavior had already begun by late childhood.  In addition, severe cases show the ego‑synthonic aggression mentioned above: sadistic character traits, chronic aggressiveness, rude behavior towards others and, in some cases, chronic self‑mutilation as a non‑specific form of achieving relief.  Some chronic self‑mutilating patients have this severe narcissistic pathology.  However, this must be differentiated from the ordinary borderline patient with self‑mutilating tendencies.  And finally, there are the severe paranoid traits, which, as you will remember, derive from the reprojection of their critical Super‑ego functions.  The combination of these four features–narcissistic personality, ego‑synthonic aggression, anti‑social

behavior and paranoid trends–constitute the extremely severe syndrome of malignant narcissism.

Malignant narcissism constitutes the most severe case of narcissistic personality which can still be treated.  There is one syndrome which is even more severe and practically untreatable, and that is the anti‑social personality disorder.  The anti‑social personality disorder is a narcissistic personality disorder involving the total deterioration of the Super‑ego.  The anti‑social personality can be differentiated from the syndrome of malignant narcissism by the following characteristics:  the anti‑social personality practically  always has a narcissistic personality usually also showing the syndrome of  malignant narcissism.  Some anti‑social personalities, however, do no show the symptom of malignant narcissism.  In them, there is the severe  anti-social behavior of a parasitic, passive type and they do not show the aggression of the syndrome of malignant narcissism.  Therefore, while the aggression of the syndrome of malignant narcissism may be present, it is not essential in the anti‑social personality.  The anti‑social personality will show, in addition, severe chronic anti‑social behavior from childhood on;  that is, incapacity for experiencing any feeling of guilt or concern, incapacity for any non‑exploitative investment in others, severe intolerance of anxiety, completely unable to feel sadness and mourning, or to faII in Iove, no sense of time or future or planning.  The result is that even psychopathic criminals are very good at short‑term planning, but totally incapable of projecting into a distant future the Iong‑term consequences of their actions.  The anti‑social personality cannot learn from experience, cannot understand moral values, in the sense that they cannot empathize with the moral dimension of others, which limits even their capacity for manipulation.  When these patients have sadistic perversions, they become extremely dangerous, because there is no control against their becoming extremely aggressive.

On the basis of what I have described so far, the overall prognosis and indications as regards treatment depends on three factors:  1) The remaining quality of object relations.  Those narcissistic personalities who still have a capacity for investment, for stability in their relations despite their many difficulties, have a better prognosis than those who are chronically totally isolated.  The most crucial factor, though, is 2) the degree of anti-social behavior.  From that viewpoint one can classify severity and prognosis in the following way:  the most severe cases are practically untreatable anti‑social personalities (in this case the treatment is mostly geared to protect the family).  Slightly less severe cases, the syndrome of malignant narcissism, are treatable usually with psychoanalytic psychotherapy, not psychoanalysis (although some cases are better treated with supportive psychotherapy rather than psychoanalytic psychotherapy). A better prognosis can be provided for 3) the narcissistic personality with some anti-social behavior, but not for the syndrome of malignant narcissism.  Here the treatment is either psychoanalytic psychotherapy or psychoanalysis.  The decision about psychoanalytical psychotherapy or psychoanalysis will depend on the level of severity of ego weakness.  Most narcissist personalities appear to have ego strength, because the pathological Grandiose Self keeps them together.  Ego strength means practically that they have anxiety tolerance, impulse control, some capacity for sublimatory functioning (which means the capacity to work and create beyond simply narcissistic survival).  However, those narcissistic personalities who, in spite of their pathological grandiose Self, show severe ego weakness, should be treated with psychoanalytic psychotherapy rather than psychoanalysis.  These are narcissistic personalities with a severe lack of anxiety tolerance, of impulse control and sublimatory functioning.

Cases of malignant narcissism usually need psychoanalytically oriented psychotherapy. lf they are not excessive, ordinary cases of narcissistic personality with some anti‑social features, can be treated by psychoanalytically orientated psychotherapy or psychoanalysis, depending on the degree of ego weakness or ego strength.

I will attempt here to very briefly differentiate these three types of treatment: psychoanalysis, psychoanalytic psychotherapy and supportive psychotherapy.

Psychoanalysis consists in the use of interpretation as the dominant therapeutic tool, a systematic analysis of the transference, and a position of technical neutrality.  In psychoanalytic psychotherapy as well the main technical instrument is interpretation, but interpretation with much more emphasis on the clarification of what is going on inside the patient’s mind.  It is confrontation, in the sense of tactfully bringing together our observations of what the patient cannot see in himself with that which he experiences–and a limitation of interpretation to the unconscious meanings in the here and now.  That is the difference between interpretation in psychoanalysis and interpretation in psychoanalytic psychotherapy.

In psychoanalytical psychotherapy the transference is also analyzed, at transference analysis is linked much more closely to the immediate external reality of the patient’s life.  Transference analysis is also modified by linking it consistently to the external reality of the patient and the long range goals of the treatment.

Technical neutrality in psychoanalytical orientative psychotherapy is modified in the sense that severe acting‑out in the sessions may force the therapist into limiting the setting, which means moving away from technical neutrality.  This then requires a reinstatement of technical neutrality trough interpretation of the reasons for which the therapist abandoned it.

That essentially differentiates psychoanalytically orientated psychotherapy from psychoanalysis.  Supportive psychotherapy is characterized by the use of clarification, confrontation, but not interpretation of unconscious meaning, but by re‑education with cognitive and emotional support and direct environmental intervention instead.  These are the techniques of supportive psychotherapy.

In supportive psychotherapy the transference is not interpreted but confronted, and the therapist teaches the patient the inappropriate nature of his transference behavior in order to reduce the transference.  It is a re‑educative transference reduction which is then used to transfer that knowledge to the patient’s life outside the sessions.  Technical neutrality here is unimportant.  In supportive psychotherapy, the therapist is not technically neutral, but takes that side of the patient’s conflicts that helps the patient to adapt better to the environment.  That means that sometimes the therapist is on the side of the Super‑ego, to teach the patient not to behave anti‑socially, and at other times on the side of the Id, to help the patient obtain more gratification from life, etc.  Thus, there is no technical neutrality, but a position on that side of the conflict which can be used adaptively.  The danger to be avoided in supportive psychotherapy is infantilizing the patient.

To conclude, I should like to talk about the main technical difficulty in all the psychotherapies, with these patients.  The most important problem is that created by the pathological Grandiose Self.  the patient’s incapacity to depend on the therapist.  It is important to analyze this difficulty in psychoanalysis and in psychoanalytically oriented psychotherapy by analyzing the ways in which this incapacity to depend shows.  The patient easily idealizes the therapist and easily devalues him, and the therapist must be attentive to these rapid fluctuations, ventilating them to the patient, pointing how he idealizes excessively and how this turns rapidly into a devaluation with the consequence that the patient risks ending the treatment.

The patient shows typical manifestations of primitive defense mechanisms, such as omnipotence, omnipotent control and devaluation.  The omnipotent control, particularly, shows in the patient’s wish to keep the therapist at a very high level.  To keep the idealization, the therapist, to be great, as great as the patient, because if he cannot be kept at a level which is as ideal as the patient’s, he has to be devalued.  So the patient tries to force the therapist to conform to his ideal picture. At the same time the therapist cannot be better than the patient, because then the patient would immediately feel devalued and inferior.  The therapist has to be as good as the patient, no worse, but also no better.  This shows in the patient’s reaction to what the therapist says, always very critical when the therapist says something different from what the patient expects the perfect therapist to say.  And this needs to be ventilated a interpreted repeatedly.

Another manifestation of the pathological Grandiose Self is a patient’s assumption that the therapist is as self‑centered as the patient.  He cannot trust the therapist’s authentic interest.  lf the therapist is interested in the patient, it is because he is getting something:  money, prestige scientific knowledge.  The patient cannot conceive of an authentic human interest, and that also needs to be interpreted.  In fact if the patient becomes convinced that the therapist has a real human interest in him, he may become envious of that capacity of the therapist which could cause a negative therapeutic reaction.

The patient frequently tries to guess how the therapist arrives at his conclusions, to outguess the therapist, because he feels that the therapist s a bag of magic tricks, gimmicks.  The patient wants to absorb these tricks to become as powerful as the therapist.  But, of course, once he has absorbed them, he unconsciously devalues them and ends up feeling empty.  What the patient has difficulty in tolerating is the therapist’s creativity, the therapist’s knowledge and emotional availability,  the therapist’s capacity to create meaning in the understanding of the patient.  Because the patient cannot count on his own emotional depth, he cannot tolerate emotional depth in the therapist, and that also must be interpreted.

The more anti‑social elements the patient has, the more he thinks the therapist is dishonest, and, under conditions where the patient feels that human relations are dishonest and where he, therefore, feels free to be dishonest with the therapist, we have the condition constituted by psychopathic transferences.  When psychopathic transferences dominate, they must first of all be interpreted–in other words, all the reasons for which he thinks the patient is dishonest, all the ways in which he attributes dishonesty to the therapist.  When that is ventilated, usually severe paranoid transferences emerge, and they, in turn, have to be interpreted and resolved.  When that is done in advanced stages of the treatment, depressive transferences dominate.  For the first time the patient can accept his own aggressive tendencies without having to deny them; he can accept guilt feelings and reorganize his Self‑concept in a more realistic way.

Once the treatment reaches a more advanced stage and the transference deepens, the components of the pathological Grandiose Self tend to be projected onto the therapist, so that the grandiose Self decomposes into object relations from the past that repeat those traumatic relationships with significant others, which caused the pathological narcissism in the first place.  At that stage, there may be both intensely positive and intensely negative transferences with sharp splitting between idealization and persecution in the transference and severe regression.  So in advanced stages of the treatment of narcissistic personalities, those transferences seem much more like the typical regressive transference of borderline patients.  This is because the underlying primitive structure is really borderline, and at that point there may be strong suicidal tendencies;  there may be paranoid micro‑psychotic episodes;  there may be severely sadomasochistic transferences and violent rage attacks.  But, as a result of this, the relationship deepens and becomes humanized, in contrast to the false calm of the beginning of the treatment when there is no real dependency.  And the therapist is aware of those changes in his counter‑transference, because the initial counter‑transference with these patients is often one of boredom;  the therapist falls asleep because of the emptiness, the lack of a human relationship, while in advanced stages there is the intensity of a real emotional relationship.

The patient has to learn first of all to tolerate the immense envy that emerges in the treatment.  That is very painful, but if envy can be tolerated, it can gradually be worked through.  Eventually, the tolerance envy makes it more conscious, decreases the need to devalue what he has received, and opens the possibility for gratitude.  As the patient becomes able to experience gratitude for what he has received from the therapist, he for the first time feels fullness, fulfillment:  he no longer feels empty, and that discovery powerfully promotes further therapeutic progress.  The envy of the other sex is a very important issue and should be explored in depth because it will permit the patient to establish more satisfactory love relations and enjoy a relation with someone who is different from him and will remain such.  The patient must learn to love and be gratified by that which he can never fully absorb into himself.

 



 

18/02/2021

 

Published by I.S.A.P. - ISSN 2284-1059