The story of Narcissus is old and it has been told in many forms. It comes from the Roman poet “Ovid”, Book III of 15. Metamorphoses, and goes something like this:
Narcissus is a handsome young man who regularly spurns the advances of many lovers, including, and especially, the nymph Echo. Echo was named this way because she was cursed to only have the capability to “echo” the sounds that others make. When Narcissus rejects Echo whom the gods essentially felt sorry for, Narcissus was punished by making him fall in love with his own reflection which he saw in a pool of water. (Note how reflection and echo have similarities. The gods were not fools). Finding that the object of his love always loves him (due to the reflection, when he smiles his reflection smiles), but cannot love him back because there is no physical presence in a reflection, Narcissus ultimately pines away and dies. It is said, by way of epitaph, that because the gods felt sorry for Narcissus, They created a memoriam. They caused a narcissus to flower in the absence of Narcissus.
The Narcissistic Personality Disorder
Probably one of the most pervasive male psychopathologies, Narcissistic Personality Disorder (NPD) or megalomania, a precursor term, has been around for as long as Freud. This is at least in the sense of this pattern of behavior as a concern or problem.
Credit to its first articulation is difficult to establish. Perhaps it was Freud who in the 1920’s noticed that some men were in possession of great libidinal influence. Others, about the same time, noticed this phenomenon (mostly in men). For example, in 1925 when Alec Wilder a New York writer described the phenomenon among stock brokers prior to the Great Depression. Needless to say, the narcissist was a type of person characterized by condescension, feelings of superiority to others, frequently preoccupied with himself, and constantly seeking the admiration of others for his superior personal qualities. Distinguishing features of the narcissist, at that time (and today as well), were lack of empathy, an intense focus on sexuality for pure pleasure rather than emotional intimacy, an insatiable need to be liked and admired. Drive for power, money, fame, or all of the above occur frequently at the expense of others. Early views of Narcissism was that these persons were highly independent, extraverted, not easily intimidated, aggressive, unable to love or commit to close intimate others. Refinements in the definition emerged in later years including that this trait also appeared in women. Ayn Rand (the contemporary philosopher) was likely, by her behavior and interpersonal character, a narcissist.
The component of “self-preservation” was introduced in our contemporary era in that the narcissist is preoccupied with self-preservation at all costs.
A pervasive pattern of grandiosity (fantasy or behavior), need for admiration, lack of empathy, began to emerge as a clear description of the disorder including that it was present and unchangeable by early adulthood, as indicated by at least five of the following:
Grandiose sense of self-importance (e.g., exaggerates achievements, expects to be recognized as superior without actually completing the achievements)
Preoccupied with fantasies of success, power, brilliance, beauty, or perfect love.
Believes that they are "special" and can only be understood by or should only associate with other special people (or institutions).
Requiring excessive admiration.
A sense of entitlement, such as an unreasonable expectation of favorable treatment or compliance with expectations).
Exploitative or takes advantage of others to achieve one’s own ends.
Lacking in empathy or unwilling to identify with the needs of others.
Envious of others or believes that others are envious of them.
Arrogant or haughty in behaviors and attitudes
Personality Disorder Defined
I digress at this point to describe the term “Personality Disorder” because it was in the 1950s when the politics of mental health were moving in the direction of labeling by virtue of “Scientific Study.” That the notion of Narcissism morphed into “Narcissistic Personality Disorder” and it was included in a manual that grouped it as a disease, versus an extreme variant of social functioning. This terminology adjustment has implications for the intrapsychic phenomenon of narcissism in the form of labels and stereotyping.
Personality Disorder Defined is: A class of mental disorders characterized by ongoing rigid patterns of thought and action.
Personality disorders are believed to be caused by a combination of genetic and environmental influences. Your genes may make you vulnerable to developing a personality disorder, and a life situation may trigger the actual development of the disorder. This is why you see the disorder in people who have difficult, traumatic childhoods and in those who have had nearly charmed growing up years.
Specific factors in the family or early life, of course, can increase or decrease the likelihood that the behavior will manifest itself:
Family history of personality disorders or other mental illness (genetic)
Abusive, unstable or chaotic family life during childhood (environment)
Being diagnosed with childhood conduct disorder (environment + genetic)
Being raised in a very morally conscious family structure (environment)
Variations in brain chemistry and structure (genetic)
There is a list of personality disorders, and this list has changed (grown, altered, shrunk) based, again, on the political tempo of the times in the medical and scientific fields, particularly psychiatry, neurology, human biology, evolutionary biology, psychology, and more recently, social work and social anthropology.
Below is a list. Yes, it is now long which means that some characteristics of personality disorders would fit nicely in the general population. I note this because I am frequently asked the question: “Dr. Do I have a personality disorder?” Most of the time my answer is “NO” because, by definition, Personality Disorders are not normative, are comprehensive, but impact only a small subset of the Western U.S. population.
10 Most Common Personality Disorder Labels
Paranoid
Schizoid
Schizotypal
Antisocial
Borderline
Histrionic
Narcissistic
Avoidant
Dependent
Obsessive Compulsive
Over time, I will probably have an entry for each one of these because the features of personality disorder represent an array of behaviors that interest almost everyone who is a student of human behavior and intrapsychic influence. A few features of personality disorder that you can always count on, I’ve listed below:
Essential Characteristics of Personality Disorders
The disorder never goes away or one is never “cured.”
PD: “Puts those cared about the most in the worst possible situations.”
The more pervasive the personality disorder the more miserable a person.
There are no drugs or medical interventions to treat PD.
Lifetime management is required in PD.
The Case of Tom
Tom, a 42 year old surgeon, was referred to me by his treating physician. Tom had recently had an entangled affair with one of the medical technicians at work and he had been reprimanded by his supervisor. Tom had been told to get counseling or he would lose his job, and there was a reasonable chance that the 25 year old female medical assistant would bring formal charges against Tom for workplace harassment which tom vehemently denied. “Doctor, this was consensual and I suffered more than she did.”
In the last 10 years, Tom had been married twice, had children from the first marriage who were now teenagers. He had lived in several homes, mostly because he had been forced to move out when the affairs (which were always substantially entangled with work, friendships, other kinds of relationships) were discovered. Currently, he was living in a luxury apartment downtown where he said he enjoyed due to the easy access to night-time activities. Tom was an excellent surgeon (by his report) and took his work very seriously. He noted that when he was “in surgery” all game-playing stopped and his focus was almost rifle barrel. His area of surgery was specialized, so I was glad to hear that he was so meticulous about what he did.
Tom grew up in the Midwest. His home was fractured, father was a military man, drank heavily, but Tom said that the father wasn’t an alcoholic. Tom described his father as aloof, had an iron will, and tolerated very little “monkey business” when he was growing up. His mother was, as Tom described her, seriously histrionic. She was constantly ill with a headache, pains of one form or another, and at times she was overcome with fainting spells. His father treated her lovingly, but he was again, aloof. So, by Tom’s report, I wasn’t sure what the term “lovingly” meant. He said he never saw his parents show any form of public affection. His Mom would frequently say, “Tom, I’ve had sex three times in my life. Once for you, once for your sister, and the first time because I was curious about it.” This, according to Tom, was the extent of his sex education as a child.
Growing up, Tom was active in sports, a competitive swimmer and tennis player. He said he liked swimming best because it naturally trimmed your physique and he enjoyed the small bathing suits so he could size up whether or not a particular girl, in high school, would be good or not good. He flirted and dated most of the girls on his swim team. He liked the divers best “they were risk takers by nature,” he said. So much so, that he got a reputation as an “aquatic Don Juan.”
He didn’t have many male friends, friendships in high school were superficial. He did go on an LDS mission at 19 years. He didn’t want to because he said the Mormon religion was “bullshit” from the get-go, but he went anyway. Got in trouble for flirting with female missionaries and enjoyed seeing whether he could tempt female missionaries to lose their faith over him.
Tom was intellectually impressive, kept himself very up-to-date reading scientific journals. He easily got into Medical School at a ranking Ivy League College, and sailed through medical school. He loved the stimulation of medical school, especially rotations and the residencies. Always a shining star, but difficult to pin down. Had no trouble with long hours or intense scheduling, or challenging assignments. The only consistent complaint he got was that his bedside manner wasn’t great, and that’s why he chose surgery. He said, “you don’t have to worry about making small talk when the patient is anesthetized.
When asked about his marriages, he seemed whimsical. Said,
“…honestly, Bob, I can call you Bob can’t I?… I don’t remember much about my first marriage, I think her name (pause)… Mary, yeah, that was her name, she was a beauty, but she was demanding, insecure, sick all the time just like my Mom, always wanted to control my life. I just couldn’t stand to be around her after a while, so the affair with - I can’t remember her name - was probably inevitable… because it ended it all quickly. Like cutting out a cancer. Sounds pretty bad doesn’t it…(while he is smiling at me).”
Tom was a difficult client. He paid in cash, my full fee, didn’t want anything about our sessions recorded. And, he constantly pushed the boundaries, missing sessions and then just paying for them. Sometimes when a session went well, at least he thought it went well, he would try and pay me double my fee. “Don’t worry,” he’d say, “call it a professional courtesy.” He really wanted me to like him, at the same time, there were sessions where he seemed bored and was ready to stop.
He talked of fantasies he had when he was young of knights and armor. Rescuing maidens in distress. Being the center stage, or taking center stage when no one else was or would do it. He saw himself in heroic terms, but he didn’t act heroic all the time, easily willing to betray a work colleague whom he thought was acting stupid or getting in his way, especially when a nurse was slow. He was sharp and curt with staff, and he wanted to work on this, to be more patient with others.
Tom was also very lonely. He would get into patterns of self-worthlessness, as the sessions progressed, he would get tearful when he felt alone or discarded by others. He said he didn’t want to Marry again, for one, he couldn’t afford it. Then he would laugh. Tom was constantly consulting and earning money on the side. He called it his side-hustle and he put the money aside for spending only on himself, sometimes hiding it from others, sheltering it from taxes. This was “his” money. He earned this money.
Tom didn’t think too much about the future, but he did bring up the past. Past instances when he was embarrassed. In the beginning, it was not easy for him to admit mistakes, but this evolved slowly over time.
This is the beginning picture of Tom. Would you consider Tom an easy client to deal with? Have you met people like Tom before? Do you see aspects of yourself in Tom? What kind of approach would you engage in if you wanted to really help Tom with his troubled world?
These are questions I asked myself ongoing as I saw Tom, week after week, month after month, and then the months turned to years…
As we move through this section I will introduce how a Psychotherapist might intervene with someone like this. Tom, who clearly has a Narcissistic Personality Disorder.
Do I have Narcissistic Personality Disorder?
Below is a short, but well-known public domain assessment for Narcissistic Personality Disorder.
I’ve grouped each statement pair. Circle the statement in each pair that matches how you feel.
1.
A. I have a natural talent for influencing people.
B. I am not good at influencing people.
2.
A. Modesty doesn't become me.
B. I am essentially a modest person.
3.
A. I would do almost anything on a dare.
B. I tend to be a fairly cautious person.
4.
A. When people compliment me I sometimes get embarrassed.
B. I know that I am good because everybody keeps telling me so.
5.
A. The thought of ruling the world frightens the hell out of me.
B. If I ruled the world it would be a better place.
6.
A. I can usually talk my way out of anything.
B. I try to accept the consequences of my behavior.
7.
A. I prefer to blend in with the crowd.
B. I like to be the center of attention.
8.
A. I will be a success.
B. I am not too concerned about success.
9.
A. I am no better or worse than most people.
B. I think I am a special person.
10.
A. I am not sure if I would make a good leader.
B. I see myself as a good leader.
11.
A. I am assertive.
B. I wish I were more assertive.
12.
A. I like to have authority over other people.
B. I don't mind following orders.
13.
A. I find it easy to manipulate people.
B. I don't like it when I find myself manipulating people.
14.
A. I insist upon getting the respect that is due me.
B. I usually get the respect that I deserve.
15.
A. I don't particularly like to show off my body.
B. I like to show off my body.
16.
A. I can read people like a book.
B. People are sometimes hard to understand.
17.
A. If I feel competent I am willing to take responsibility for making decisions.
B. I like to take responsibility for making decisions.
18.
A. I just want to be reasonably happy.
B. I want to amount to something in the eyes of the world.
19.
A. My body is nothing special.
B. I like to look at my body.
20.
A. I try not to be a show off.
B. I will usually show off if I get the chance.
21.
A. I always know what I am doing.
B. Sometimes I am not sure of what I am doing.
22.
A. I sometimes depend on people to get things done.
B. I rarely depend on anyone else to get things done.
23.
A. Sometimes I tell good stories.
B. Everybody likes to hear my stories.
24.
A. I expect a great deal from other people.
B. I like to do things for other people.
25.
A. I will never be satisfied until I get all that I deserve.
B. I take my satisfactions as they come.
26.
A. Compliments embarrass me.
B. I like to be complimented.
27.
A. I have a strong will to power.
B. Power for its own sake doesn't interest me.
28.
A. I don't care about new fads and fashions.
B. I like to start new fads and fashions.
29.
A. I like to look at myself in the mirror.
B. I am not particularly interested in looking at myself in the mirror.
30.
A. I really like to be the center of attention.
B. It makes me uncomfortable to be the center of attention.
31.
A. I can live my life in any way I want to.
B. People can't always live their lives in terms of what they want.
32.
A. Being an authority doesn't mean that much to me.
B. People always seem to recognize my authority.
33.
A. I would prefer to be a leader.
B. It makes little difference to me whether I am a leader or not.
34.
A. I am going to be a great person.
B. I hope I am going to be successful.
35.
A. People sometimes believe what I tell them.
B. I can make anybody believe anything I want them to.
36.
A. I am a born leader.
B. Leadership is a quality that takes a long time to develop.
37.
A. I wish somebody would someday write my biography.
B. I don't like people to pry into my life for any reason.
38.
A. I get upset when people don't notice how I look when I go out in public.
B. I don't mind blending into the crowd when I go out in public.
39.
A. I am more capable than other people.
B. There is a lot that I can learn from other people.
40.
A. I am much like everybody else.
B. I am an extraordinary person.
To score:
For each of the following where you answered A give yourself one point: 1, 2, 3, 6, 8, 11, 12, 13, 14, 16, 21, 24, 25, 27, 29, 30, 31, 33, 34, 36, 37, 38, 39
For each of the following where you answered B give yourself one point: 4, 5, 7, 9, 10, 15, 17, 18, 19, 20, 22, 23, 26, 28, 32, 35, 40
Record Your Total Score: ______
A score you calculate should be between 0 and 40. Below is a graph of the distribution of how others score on test. Most people score between 7 and 12. Scores above 30 may represent NPD. In other words, if you score above 30, this is similar to how a person with NPD might respond to these questions.
This area is NPD likely
Below is a figure that Diagrams how the score on this inventory could be interpreted. Keep in mind that answering affirmatively on many of these questions is adaptive, even desirable. But, taken as a whole, an imbalance of affirmative responses (scoring 30 or higher) suggests a viewpoint of exclusion and control that will make it very difficult for a person to interact in a positive, pro-social way with most people.
This exercise underscores my point that like most personality disorders, there are traits or qualities that are adaptive and positive. It is the “preponderance” of one-way thinking (sometimes to the exclusion of thinking any other way) that makes a personality disorder so harmful to the person and to those persons around someone with a personality disorder.
In my practice, I have treated more than 50 people with Narcissistic Personality Disorder, so I have a deep template of how this kind of person thinks, feels, and interacts with the world. Most of the time, people in this category feel unfulfilled, bored with others, bitter towards their past (or features of their past) others, or their circumstances. They realize something is not right with them, but they just can’t quite understand what it is. Sometimes they get angry with me, the therapist, because I’m not quite available enough for them, or that I disappoint them in some small way. They tend to be impatient with their circumstances and this is hard to treat. They want things to change, “now.” It is difficult for them to be patient and understanding of the needs of others. They will hurt people on a whim. They can easily do damage to themselves, often without awareness. Sometimes they drift into states where they feel like they are a different person. Sometimes they say, “Just Fuck it” and give into their impulses, almost as if they have no choice.
They are almost always initially very endearing, charming, sometimes they can seem desirable, funny, charming, quick witted, and this is both men and women. But, its not long until that demanding, seemingly uncaring, feature starts to emerge. People in this category frequently identify trauma in their early life, but it is difficult to interpret it. In the end, working with this kind of client is satisfying because as they develop insight and understanding about themselves they can make surprising and large, sustained changes, but they are always working against that feature of themselves that has a need that just can’t ever seem to get met. Usually, they’ve created a mess of their lives, so, they might want to give up, but that’s where an expert therapist makes a difference. “Never give up.” Is my adage in working with a narcissistic personality disorder, so, not surprisingly, I see this client, not for short bursts of education (that you might find in Cognitive Behavioral Therapy), but, for the long haul, with relationship development, behavioral pattern adjustment, values clarification and shaping, character development. These are character traits, that for some reason or another, never got solidified in childhood.
What are your thoughts about this kind of individual?