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HARVARD MEDICAL SCHOOL

Harvard Mental Health Letter


VOLUME 20 NUMBER 8 FEBRUARY 2 0 0 4

Narcissism and self-esteem


Psychotherapists try to discourage one, encourage the other, and understand how INSIDE the two are related.

he mythical Narcissus rejected all lovers, then fell in love with his own reflection in a forest pool. The psychiatric definition of narcissistic personality includes many destructive forms of selflove not only vanity but self-importance, self-absorption, self-centeredness, and a patronizing or contemptuous attitude toward others. It is a problem in its own right and a complication in the treatment of many psychiatric disorders. But narcissism is also related to self-esteem, which psychotherapists usually regard as valuable and want to encourage. So it becomes especially important to distinguish narcissism from self-esteem and related traits self-liking, self-acceptance, and self-confidence. As described in the American Psychiatric Association's diagnostic manual, narcissistic personality disorder is characterized by feelings of superiority and a sense of entitlement. Narcissistic personalities need to feel unique. They rely upon an unrealistic view of their talents and prospects, and may dream of unlimited fame and power and ideal love. In their eyes, their problems and needs, like their gifts, are extraordinary and deserve priority. They demand attention and admiration and expect special favors as a right. Narcissistic personalities pay Httle attention to other people's feelings and wishes. They are interested in others mainly as mirrors in which they can admire their own features the pool of Narcissus or as instruments for satisfying their wants. They freely take advantage of others and expect gratitude in return. The other side of their arrogance is envy. They tend to be both envious and contemptuous of others.

especially those they regard as their rivals, while openly conveying a belief that others envy them. Like other personality disorders, narcissistic personality rarely occurs in pure form. It's one of a group of disorders that also includes borderline, antisocial, and histrionic personalities. Two-thirds of people diagnosed with narcissistic personality disorder also qualify for one of these diagnoses, partly because they involve many of the same traits. Histrionic personality is characterized by a craving for attention and admiration; antisocial personality by arrogance and disregard for the feelings of others; and borderline personality by emotional volatility, especially when important relationships become disappointing. Although it's not part of the American Psychiatric Association's definition, most mental health professionals believe that the self-love of narcissistic personalities is precarious and easily threatened. They can avoid acknowledging failure by setting low standards that are easily met if at first you don't succeed, act as though you never tried. When nothing else works, they may blame their failures on others. They require, expect, and demand constant support for their high opinions of themselves, so they feel surprised and betrayed when they are criticized or rebuffed in any way. Then, to maintain the image of themselves as superior, they may lash out in an angry counterattack. They may also react to a setback with shame. Some psychiatric clinicians believe there are narcissistic personalities who do not show the obvious signs detailed in the diagnostic manual. They don't openly claim superiority or a right to special treat-

Recovering from schizophrenia

There is no cure, but many people with this disorder cope surprisingly well in the long run

In brief Lifesaving lithium: New research favors an old drug ... 7 Reliving trauma: It is effective for some, but too many drop out 7 Q&A: Are there any good drug treatments for binge eating disorder?

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Editor In Chief Michael Craig Miller, MD Editor James B, Bakalar, JD Founding Editor Lester Grinspoon, MD Editorial Board Mary Anne Badaracco, MD Paul Barreira, MD Robert J, Birnbaum, MD, PhD Jonathan F, Borus, MD Barbara Coffey, MD Steven H, Cooper, PhD Christopher B, Daly Frank W, Drislane, MD Anne K, Fishel, PhD Donald C, Goff, MD Alan I. Green, MD William E, Greenberg, MD SheUy Greenfield, MD, MPH Thomas G, Gutheil, MD Michael Hirsch, MD J,AUanHohson,MD Steven J, Kingsbury, MD, PhD Michael J, Mufson, MD Andrew A, Nierenherg, MD Hester H, Schnipper, LICSW, BCD Barbara Wolfe, PhD, RN Editorial Board members are associated with Harvard Medical School and affiliated institutions. They review all published articles. Copy Editor Pat Cleary Design Editor Heather Foley Production Editor AmyYeager

Narcissism continued

ment. They may even seem superficially modest, anxious, and dissatisfied with themselves. But these "vulnerable" narcissists harbor a secret arrogance. They are argumentative and demanding and sometimes explode in anger, which is followed by shame and depression. To avoid rejection that would damage their self-esteem, they may become so socially withdrawn that they resemble avoidant personalities. Looked at this way, narcissism must eventually lead to disappointment, and the question is whether a person will respond to the disappointment by feeling ashamed and withdrawing, or by angrily reasserting superiority. Either way, it is unhealthy. Narcissus drowned when he tried to embrace his reflection.

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Psychoanalytic views
The idea of narcissism comes to psychiatry through the psychoanalytic tradition, and it was elaborated mostly by two psychoanalysts. Otto Kernberg and Heinz Kohut. Both emphasized the vulnerability that underlies narcissistic arrogance, but they disagreed about the development and treatment of narcissistic personality. Describing their ideas requires some specialized language that may seem forbidding. According to Kernberg, our childhood inner worlds contain representations or images of people who are emotionally significant, especially ourselves and our parents. These "objects" and our relationships with them are the keys to an understanding of narcissism. Kernberg believes that narcissistic personality is a response to coldness, indifference, or hidden aggression on the part of parents who, without being truly affectionate, try to convince a child of his or her own importance. Narcissistic personalities live in fear of these persistent internal images of parents to which they attribute their
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Harvard Health Publications 10 Shattuck St,, Suite 612, Boston, MA 02115 The goal ofthe Harvard Mental Health Letter is to interpret timely mental health information. Its contents are not intended to provide advice for individual problems. Such advice should be offered only by a person familiar with the detailed circumstances in which the problem arises. We are interested in comments and suggestions about the content; unfortunately, we cannot respond to all inquiries.

own anger at the treatment they received in childhood. They feel that they cannot be loved unless they are perfect. Their internal objects, representations that remain in the mind, are never assimilated and integrated, and their adult relationships are distorted. They cannot distinguish their real abilities from grandiose fantasies or live up to the internal image of an ideal parent. Their superficial selfsufficiency is belied by their envy and craving for admiration. This implicit self-image of the narcissistic personality provides a defense for the ego an unconscious way of coping with the stress of internal conflict. The defenses used by narcissistic personalities are immature, involving a denial of responsibility for their own feelings and actions. These defenses include projection attributing one's feelings to others in order to avoid acknowledging them and idealization of, or contempt for, others. Narcissistic personalities make even those they idealize into potential enemies, because they project onto these idealized figures, who are also rivals, their own wish to exploit others. Kohut regards narcissism in a way that is similar, yet different. His view is thatfi-omearly childhood on we all have "selfobjects," internalized representations of people (mainly parents) who maintain the sense of a self by reflecting a child's wishes for recognition and praise a process called mirroring. Selfobjects are also representative of a child's need to idealize, and they serve as models, creating a sense of what Kohut calls "twinship" between child and parent. As a natural stage of development, we all start out vth this "grandiose self" and an idealized image of our parents. With good parenting, these primal narcissistic selfobjects are moderated and become the basis for a mature personality. Kohut believed that the parents of
FEBRUARY 2004

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narcissistic personalities are capricious and unreliable, reject the child, or treat the child as an extension of themselves. The child grows up with a distorted view of what it means to be lovable. To defend themselves (unconsciously) against feeling imlovable, narcissistic personalities imagine themselves as perfectly lovable a self-image they need in order to receive the admiration not supplied by their parents. They view themselves as having no needs they cannot provide for themselves. But because no one is self-sufficient, this belief only leads them to become vulnerable to disappointment. Their underlying feelings of worthlessness and emptiness force them into a constant search for recognition. They enter relationships expecting others to gratify all their unconscious wishes. They do not develop either rational self-esteem or a sense of responsibility and empathy for others. Mental health professionals who treat narcissistic personalities usually say that these patients seek therapy mainly when they can no longer sus-

tain their high opinion of themselves. They may have lost a job, a lover, or a spouse. Aging or illness may have undermined their fantasies of superiority and invulnerability. This blow to self-love is called narcissistic injury. Psychotherapy cannot radically alter narcissistic personality, but it can sometimes help change thinking and behavior enough to limit its consequences. And understanding narcissistic personality can help in choosing treatments for problems like depression, anxiety, eating disorders, and substance abuse.

Treatments
People with narcissistic problems are often treated with psychodynamic (broadly psychoanalytic) therapy, which works (in part) by uncovering mechanisms of defense and tracing their origins in the emotional conflicts of early life. An important part of this process is transference the re-emergence of childhood feelings for parents in the relationship with the therapist. Here, Kohut concentrates on a positive transference and Kernberg on a negative one.

environment in which they can temporarily serve as a good parent and allow arrested emotional development to resume. The therapist should allow feelings of mirroring, idealization, and twinship to develop without interpretation or criticism until the time comes to show their limitations. Once the self has been strengthened, the narcissistic transference can be gently challenged so that the psychotherapist is acknowledged as an independent person no longer unconsciously conceived as identical to the patient whose limitations are not a betrayal of trust. This allows the patient to achieve a form of selfesteem that is not illusory.

Kernberg's approach
Kernberg thinks the therapist must be more challenging from the start. He believes that the narcissistic self is not simply immature but distorted and in need of correction. The idealizing transference and the underlying envy and contempt must be confronted immediately and interpreted as a result ofthe patient's yearning for loving care from a parent. Kernberg treats idealization as a defense against fear of attack from a therapist to whom the patient has attributed his own anger. Psychoanalysis and psychodynamic therapy also require an analysis of the countertransference the feelings of the therapist for the patient, which reflect both the patient's and the therapist's unconscious emotional conflicts. Narcissistic patients can be difficult to treat. Ungrateful, dismissive, demanding special treatment, they can make psychotherapists uncomfortable, angry, or ashamed of their limitations and defects. Psychotherapists may begin to feel ineffectual and incompetent, or on the contrary, may become too fond of being idealized. The therapist must recognize these feelings, put them in context, and use them to better understand the patient.
HARVARD MENTAL HEALTH LETTER

Groopman LC, et al. "Narcissistic Personaiity Disorder," in Gabbard GO, ed.. Treatments of Psychiatric Disorders, Second Edition, American Psychiatric Press, 1995, Kernberg OF. Borderline Conditions and Pathological Narcissism. Jason Aronson, 1995, Kohut H. Analysis of Self, internationai Universities Press, 2000. Kraus G, et al. 'Tiie 'A-B-C's' of the Ciuster B's: Identifying, Understanding, and Treating Ciuster B Personaiity Disorders," Clinical Psychology Review (April 2001): Voi, 21, No. 3, pp, 345-73. Mruk CJ, ed. Self-Esteem: Research, Theory, and Practice. Springer, Second Edition, 1999, For more references, piease see www,health.harvard,edu/mental.

Kohut's approach
According to Kohut, narcissistic personalities develop three kinds of responses, corresponding to their mental representations of key childhood relationships. In mirroring the purest sense of narcissism the therapist provides a reflection in which they can admire themselves. A narcissistic patient also may identify with an idealized therapist to gain strength. Finally, in twinship, the therapist becomes an alter ego on which they can model themselves. Kohut believes that in the beginning, narcissistic patients need the therapist as what he calls a primitive or archaic selfobject the function served by parents in early childhood. Therapists should let themselves be used in this way because it creates an
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FEBRUARY 2004

other therapies
If the patient is seeking help because of a marital crisis, couples therapy can be added to individual treatment. Group therapy is another possibility. Narcissistic patients create difficulties because of their hunger for admiration, their envy, and their willingness to take advantage of others. There's a danger that they will simply be given free rein to talk about themselves. But groups also offer an opportunity to confront their behavior safely and expose underlying needs and feelings. At the same time, they can see how their behavior affects others and may become genuinely involved with the problems of other people for the first time.

The self-esteem paradox


The psychodynamic way of thinking about narcissism and its treatment raises the question of when self-love is justified and reasonable. As psychoanalysts recognize, narcissistic needs and vulnerability are normal. Most people want to like themselves, prove themselves, and be proud of themselves. They can be competitive, and they are capable of feeling envy and shame. Recognizing one's own virtues and talents is desirable. Thinking well of yourself is good for you; for example, it's been shown to be associated with- quicker physiological recovery from stress, as measured by levels of stress hormones. The philosopher Aristotle wrote that the "magnanimous" person who demands and receives deserved honors represents a virtuous golden mean between those who claim too much and those who claim too little for themselves. It would be easy to say that narcissism is illusory or defensive as opposed to genuine self-esteem. But studies show that even illusory self-esteem is good for mental health and personal relations. In psychological experiments, people with high but healthy self-esteem take more credit for suc-

cess than they deserve and less blame for failure. And even those whom others like most nevertheless have optimistic illusions about how much they are liked. According to some studies, depressed people are actually more realistic about themselves, their prospects, and the way others regard them sadder but wiser. It seems paradoxical to say that a person with limited self-knowledge is able to act well and function effectively. The distinction between selfesteem and narcissism seems to disappear. One way to think about this paradox is to say that having too good an opinion of yourself in a vague and general way is compatible with reasonably acknowledging your limitations in most real-life situations. That is where narcissistic personalities fall short. Self-esteem is a matter of degree, and the low end of the continuum often leads to depression or a depressive personality. Many psychiatric patients suffer from low self-esteem, and it can be a vicious cycle. It's easy

to maintain a poor opinion of oneself because others regard pessimism and apathy as evidence of inferiority. The effect is to confirm expectations of failure and reinforce self-defeating attitudes. Low self-esteem can sometimes be raised with cognitive behavioral therapy, which treats incorrect thinking as a major source of emotional disorders. Therapist and patient reevaluate the patient's beliefs by restating them as hypotheses to be tested in action. At least in the short run, studies show that this treatment is often effective. But whether raising self-esteem should be a target of psychotherapy, as opposed to a byproduct of treatment for depression and other conditions remains controversial. The challenge is to confront grandiose attitudes toward the self at the same time. In treating narcissistic personalities, encouraging the right kind of selflove while promoting realistic attitudes toward oneself and others is a difficult but worthwhile therapeutic challenge. W

Recovering from schizophrenia


he idea that it's possible to recover from schizophrenia has been popularized by the story of John Nash, as told in the biography andfilm,A Beautiful Mind. The Nobel Prize-winning scientist began to suffer delusions and hallucinations in his late twenties. He was diagnosed as schizophrenic, treated with antipsychotic medications, and periodically admitted to mental hospitals for nearly 30 years. The symptoms gradually faded in his forties and fifties; by age 60 he was able to stop taking medications and even return to scientific work. The story may be surprising to some because a diagnosis of schizophrenia is offen thought to imply
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progressive deterioration or, at best, permanent severe disability. One of the great early students of the disorder, Emil Kraepelin, called it dementia praecox premature dementia. But there's plenty of evidence that Nash's case is not unusual, and we may already know ways to promote relatively happy outcomes like his. A typical study revealing the possibilities included 101 patients who were interviewed five years affer the diagnosis. The outcome was described as good if they had been working at least half time and had spent less than three years in hospitals during the previous five years, had met with friends in the prior month, and had had only mild or transient psychotic
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