Imagine this story. A 32-year-old, divorced, male attorney sees a prominent physician for depression after losing an important court case. The senior law partner in his firm had criticized him for inadequate preparation. The patient is well- known in his community as a tall, attractive, intelligent man who makes friends easily. Sadly, he also loses friends quickly. His wife left him 4 years earlier because she "couldn't stand his self-centeredness" any more. His angry tirades are legend, especially when someone disagrees with his point of view on almost any topic. He is in good general health and works out regularly at the "best" athletic club in the area so he can maintain an ideal physique. At this first visit to the doctor he lets the doctor know that he was chosen because he is thought to be the best in his field. However, the patient also let's him know that he demands nothing but outstanding care to which he is entitled.
This case is not a real one but is illustrative of an extreme form of narcissism known officially as Narcissistic Personality Disorder in the psychiatric manual of Diagnostic and Statistical Disorders. The essential features of this personality disorder are a pattern of grandiosity, a need for admiration, and a lack of empathy. It begins in early adulthood and shows up in a variety of contexts.
Teenagers often have narcissistic traits, but these rarely turn out to be a harbinger of the personality disorder. Their form of narcissism is part of their normal development.
The full disorder is not common. Those that have it can be successful vocationally, but some perform below their ability, perhaps due to a fear of failing, which leads to an unwillingness to take risks and potentially fail.
It is a bit more common in men than women. The cause is not known, but clinical experience suggests that genetic temperament may play a role, and parenting style is likely to be important in its development. This may be providing excessive and undeserved praise, being overly demanding of success in all activities, or, at the other end, being neglectful.
People with this personality disorder have an inflated sense of their abilities. They crave compliments and may try to elicit them in a charismatic way. They must own the best of whatever they purchase whether it is a car, a set of golf clubs, or clothing. They are seen as boastful, "full of themselves," and self-centered. They lack empathy for others so that relationships suffer. According to Susan Heitler a PhD psychologist, the wives of male narcissists are often depressed and angry.
Their self appraisal goes well beyond healthy self-esteem, which is normal and desirable. In fact, people with this disorder have poor self-esteem underlying their outward bravado. Any criticism or failure leads to intense shame that leads to rage as a result of the narcissistic injury.
The Narcissistic Personality Disorder can lead to alcohol abuse (reduces a sense of shame), relationship problems, problems at work, and depression. Treatment takes time and consists of psychotherapy. There is no medication for the disorder per se, but they may be indicated for conditions that result, such as using antidepressants for depression.
The word, "narcissism" comes from the Greek myth of the amazingly handsome son of a river god and a nymph. A seer told his mother that he could live a long life but only if he did not see himself (know himself?). He was seen by Echo who fell in love with him and tried to pursue him. However, her love was never reciprocated because Narcissis saw his own image reflected in the water of a spring. He was so enamored with his own beauty that he could not turn away and eventually died. At the place where he died, a flower grew that was forever known as Narcissis.
The lawyer in the story at the beginning of the blog is emblematic of the type of man that Carly Simon was probably thinking of when she wrote and sang the song, "You're So Vain" in 1972. The song has a famous line, "You're so vain, you probably think this song is about you!" Does this blog sound like someone you know?
Peter M. Hartmann, MD
