Narcissistic personality diso... Health Article

Subtypes of NPD

AGE GROUP SUBTYPES.Ever since the 1950s, when psychiatrists began to notice an increase in the number of their patients that had narcissistic disorders, they have made attempts to define these disorders more precisely. NPD was introduced as a new diagnostic category in DSM-III, which was published in 1980. Prior to DSM-III, narcissism was a recognized phenomenon but not an official diagnosis. At that time, NPD was considered virtually untreatable because people who suffer from it rarely enter or remain in treatment; typically, they regard themselves as superior to their therapist, and they see their problems as caused by other people's "stupidity" or "lack of appreciation." More recently, however, some psychiatrists have proposed dividing narcissistic patients into two subcategories based roughly on age: those who suffer from the stable form of NPD described by DSM-IVTR, and younger adults whose narcissism is often corrected by life experiences.

This age group distinction represents an ongoing controversy about the nature of NPD—whether it is fundamentally a character disorder, or whether it is a matter of learned behavior that can be unlearned. Therapists who incline toward the first viewpoint are usually pessimistic about the results of treatment for patients with NPD.

PERSONALITY SUBTYPES.Other psychiatrists have noted that patients who meet the DSM-IV-TRcriteria for NPD reflect different clusters of traits within the DSM-IV-TRlist. One expert in the field of NPD has suggested the following subcategories of narcissistic personalities:

• Craving narcissists. These are people who feel emotionally needy and undernourished, and may well appear clingy or demanding to those around them.
• Paranoid narcissists. This type of narcissist feels intense contempt for him- or herself, but projects it outward onto others. Paranoid narcissists frequently drive other people away from them by hypercritical and jealous comments and behaviors.
• Manipulative narcissists. These people enjoy "putting something over" on others, obtaining their feelings of superiority by lying to and manipulating them.
• Phallic narcissists. Almost all narcissists in this subgroup are male. They tend to be aggressive, athletic, and exhibitionistic; they enjoy showing off their bodies, clothes, and overall "manliness."

Causes

At present there are two major theories about the origin and nature of NPD. One theory regards NPD as a form of arrested psychological development while the other regards it as a young child's defense against psychological pain. The two perspectives have been identified with two major figures in psychoanalytic thought, Heinz Kohut and Otto Kernberg respectively.

Both theories about NPD go back to Sigmund Freud's pioneering work On Narcissism,published in1914. In this essay, Freud introduced a distinction which has been retained by almost all later writers—namely, the distinction between primary and secondary narcissism. Freud thought that all human infants pass through a phase of primary narcissism, in which they assume they are the center of their universe. This phase ends when the baby is forced by the realities of life to recognize that it does not control its parents (or other caregivers) but is in fact entirely dependent on them. In normal circumstances, the baby gives up its fantasy of being all-powerful and becomes emotionally attached to its parents rather than itself. What Freud defined as secondary narcissism is a pathological condition in which the infant does not invest its emotions in its parents but rather redirects them back to itself. He thought that secondary narcissism developed in what he termed the pre-Oedipal phase of childhood; that is, before the age of three. From a Freudian perspective, then, narcissistic disorders originate in very early childhood development, and this early origin is thought to explain why they are so difficult to treat in later life.

CAUSES IN THE FAMILY OF ORIGIN.Kohut and Kernberg agree with Freud in tracing the roots of NPD to disturbances in the patient's family of origin—specifically, to problems in the parent-child relationship before the child turned three. Where they disagree is in their accounts of the nature of these problems. According to Kohut, the child grows out of primary narcissism through opportunities to be mirrored by (i.e., gain approval from) his or her parents and to idealize them, acquiring a more realistic sense of self and a set of personal ideals and values through these two processes. On the other hand, if the parents fail to provide appropriate opportunities for idealization and mirroring, the child remains "stuck" at a developmental stage in which his or her sense of self remains grandiose and unrealistic while at the same time he or she remains dependent on approval from others for self-esteem.

In contrast, Kernberg views NPD as rooted in the child's defense against a cold and unempathetic parent, usually the mother. Emotionally hungry and angry at the depriving parents, the child withdraws into a part of the self that the parents value, whether looks, intellectual ability, or some other skill or talent. This part of the self becomes hyperinflated and grandiose. Any perceived weaknesses are "split off" into a hidden part of the self. Splitting gives rise to a lifelong tendency to swing between extremes of grandiosity and feelings of emptiness and worthlessness.

In both accounts, the child emerges into adult life with a history of unsatisfactory relationships with others. The adult narcissist possesses a grandiose view of the self but has a conflict-ridden psychological dependence on others. At present, however, psychiatrists do not agree in their description of the central defect in NPD; some think that the problem is primarily emotional while others regard it as the result of distorted cognition, or knowing. Some maintain that the person with NPD has an "empty" or hungry sense of self while others argue that the narcissist has a "disorganized" self. Still others regard the core problem as the narcissist's inability to test reality and construct an accurate view of him- or herself.

MACROSOCIAL CAUSES.One dimension of NPD that must be taken into account is its social and historical context. Psychiatrists became interested in narcissism shortly after World War II (1939–45), when the older practitioners in the field noticed that their patient population had changed. Instead of seeing patients who suffered from obsessions and compulsions related to a harsh and punishing superego (the part of the psyche that internalizes the standards and moral demands of one's parents and culture), the psychiatrists were treating more patients with character disorders related to a weak sense of self. Instead of having a judgmental and overactive conscience, these patients had a weak or nonexistent code of morals. They were very different from the patients that Freud had treated, described, and analyzed. The younger generation of psychiatrists then began to interpret their patients' character disorders in terms of narcissism.

In the 1960s historians and social critics drew the attention of the general public to narcissism as a metaphorical description of Western culture in general. These writers saw several parallels between trends in the larger society and the personality traits of people diagnosed with narcissistic disorders. In short, they argued that the advanced industrial societies of Europe and the United States were contributing to the development of narcissistic disorders in individuals in a number of respects. Some of the trends they noted include the following:

• The mass media's preoccupation with "lifestyles of the rich and famous" rather than with ordinary or average people.
• Social approval of open displays of money, status, or accomplishments ("if you've got it, flaunt it") rather than modesty and self-restraint.
• Preference for a leadership style that emphasizes the leader's outward appearance and personality rather than his or her inner beliefs and values.
• The growth of large corporations and government bureaucracies that favor a managerial style based on "impression management" rather than objective measurements of performance.
• Social trends that encourage parents to be self-centered and to resent their children's legitimate needs.
• The weakening of churches, synagogues, and other religious or social institutions that traditionally helped children to see themselves as members of a community rather than as isolated individuals.

Although discussion continues about the location and forms of narcissism in the larger society, no one now denies that personality disorders both reflect and influence the culture in which they arise. Family therapists are now reporting on the treatment of families in which the children are replicating the narcissistic disorders of their parents.