Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Tuesday, November 3, 2015

Narcissism, Part I

Long time no see!

I've been busy teaching. And it's been  a lot of work. I'm assistant-teaching an analytic class on Affects and Affect Pathology, and I just finished solo-teaching a psychotherapy class on Narcissism. This hasn't left a whole lot of time for blogging, or doing research for blogging, so I thought I'd attempt to combine the two by sharing some of the ideas from the Narcissism class.

If you think about it for a minute, you'll realize that "narcissism" is one of those words that has so many meanings, it's meaningless.

In the early analytic literature, narcissism was used in at least four different ways:

1. To denote a sexual perversion characterized by the treatment of ones own body as a sexual object

2. To denote a stage of development

3. To denote two different phenomena in the realm of object relations:
    a. a type of object choice in which the self plays a more important part than the real aspects of the object
    b. a mode of relating to the environment characterized by a relative lack of object relations

4. To denote various aspects of the complex ego state of self esteem
(Cooper, A. M. Narcissism (1986) in Essential Papers on Narcissism, Andrew P. Morrison Editor, pp. 112-143. New York University Press)

For those not familiar with the jargon, and ironically, in psychoanalytic-speak, people are referred to as, "objects".

Importantly, we can differentiate (Freud, 1914, "On Narcissism")  between primary narcissism, in which libido is invested in the now-differentiated ego, prior to the formation of object ties, and secondary narcissism, the withdrawal of libido back into itself, after object ties have been established. These are somewhat archaic descriptions, but the bottom line is that there is a normal, healthy type of narcissism that is part of development, and there is an abnormal, unhealthy type of narcissism that forms when something goes wrong developmentally.

Why is it important to know about narcissism? Because we see it all the time. There are the blatantly obvious cases, such as the super-entitled patient with zero empathy, or as a specific example, Richard III, about whom Freud writes in, "The Exceptions".

But there are also the more subtle cases: The patient who has been unemployed for years because he is unable to give up an unrealistic dream in favor of a potentially fulfilling and attainable but less grand goal; The perfectionist who can't differentiate between a minor mistake and a paralyzing, life-ruining humiliation; The patient who is unable to view others as anything but an extension of herself, who cannot understand why her friendships and romantic relationships never last; The highly somatic patient whose concerns with his body reflect his worries about the disintegration or annihilation of his sense of self.

And finally, there are the ones who do not have a primarily narcissistic pathology, but who suffer some sort of major narcissistic injury (e.g. loss of job, spouse, friend), who in response, regress to a more self-focused, withdrawn state, sometimes in the form of depression, and who need help re-establishing ties with the world.

Some of the qualities of Narcissistic Pathology:

sense of vague falseness
defensive self sufficiency

Fear of fragmentation can be displaced into preoccupation with physical health
Denial of remorse and gratitude
Guilt or dependency is shameful
(McWilliams, N. (1994) Psychoanalytic Diagnosis. New York: Guilford Press)

defensive self inflation
lack of integration of the self concept
inordinate dependence upon acclaim of others
poor object relations
vulnerability to feelings of rage, shame, depression
relentless pursuit of self perfection
impaired capacities for concern, empathy, love for others
self aggrandizement/omnipotence
(Auchincloss, E., and Samberg, E. (2012) Psychoanalytic Terms and Concepts. Yale University Press, pp. 162-6)

And here are DSM-IV (left) and DSM-5 (right) criteria for Narcissistic Personality Disorder:

Interestingly, DSM-IV is more focused on presenting symptomatology, while DSM-5 harkens back to a more etiologic conception, with emphasis on impairments in sense of identity and self.

There is a rich literature about the role of the "self" in narcissistic pathology. Sullivan writes about "self-dynamism" formed by notions of the "good me", the "bad me", and the "not-me". Rado writes about the "action self", a gauge of a person's emotional stature.

Horney describes the loss of the "real me" under conditions of parental coercion, resulting in unproductivity, excessive expectations, grievances and hostility.

Winnicott writes about the "true self" vs. the "false self":

A True Self begins to have life through the strength given to the infant's weak ego by the mother's implementation of the infant's omnipotent expressions. The mother who is not-good-enough is not able to implement the infant's omnipotence, and so she repeatedly fails to meet the infant gesture; instead she substitutes her own gesture which is to be given sense by the compliance of the infant. This compliance on the part of the infant is the earliest stage of the False Self, and belongs to the mother's inability to sense her infant's needs.
(Winnicott, D.W. The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. New York: International University Press, 1965, p. 145.)

For narcissism, in its pathological form, development of the self is where it's at. Which brings us to self-psychology, or the Kohutians, my preferred term because it sounds science-fiction-y.

To Be Continued...