Narcissism and superego development

To elucidate the role of the superego in th maintenance of narcissistic equilibrium, we reviewed Freud's ideas about narcissism and the superego as well as the relevant theories of Kohut, Kernberg, and certain ego psychologists. These latter authors offer an alternative mode of understanding narcissism more consistent with Freud's structural theory, one in which signal affects and superego functioning play a central role in normal development and in the pathogenesis of narcissistic disturbances. Early steps in superego formation were then examined schematically to elucidate the interaction of environmental influences and emerging psychic structure. We suggested that the first step in a developmental line toward superego formation is based on the affective qualities experienced in the course of self-object differentiation. Subsequent steps examined were introject and ego-ideal formation; compliance with th object; compliance with the introject; identification with the introject and the ego ideal; and finally, with oedipal resolution, the integration of superego nuclei into a progressively structuralized autonomous superego system. This system achieves growing independence from the drives and from pressures from early introjects during the course of latency, and functions to maintain the demands of the conscience and the standards of the ego ideal; rewards or punishments result when these demands and standards are or are not met. The final stage briefly considered here was the revision, modification, and elaboration of moral codes and the ego ideal as part of the adolescent process. Narcissistic vulnerabilities at various stages were pointed out in an attempt to stress that a particular clinical picture in later phases of development or adulthood may derive from any of several development points of origin and from one or more etiological factors.     

Fear of humiliation

This paper explores the ontogeny of fear of humiliation, conceived of as an important organizing affect-laden fantasy in certain narcissistic personality disorders. The influence of the pleasure of the parental object in sadistically humiliating is emphasized in the overdetermined genesis of this fear. While, in elaboration of Loewenstein's (1957) and Eidelberg's (1959) contributions, "seduction of the humiliator" is a fundamental defensive process observed in masochistic characters, identification with the humiliator is a sadonarcissistic defense observed in work with certain narcissistic personality disorders. The countertransference potential to enjoy humiliating such analysands, as well as the defensive functions of fear to humiliation, are noted.     

Konzepte der Identifizierung

The authors investigate primary, hysterical, narcissistic identification, and introjection as conceptualised by Freud, Melanie Klein’s projective identification, and Anna Freud’s identification with the aggressor and altruistic surrender. It is pointed out that hysterical identification, narcissistic identification, and introjection are unconscious processes leading into a state of primary identification, and that they can be distinguished on a clinical level as regards the emotional meaning the object has for the subject. In hysterical identification the aspects of an object with which one identifies and all its other aspects retain their emotional meaning, in narcissistic identification these other aspects also keep their emotional meaning, but in this case the aspects with which one identifies lose their emotional meaning, and in introjection all aspects of an object lose their emotional meaning. Furthermore, it is shown that hysterical or narcissistic identifications are the mechanisms underlying the identification with the aggressor, and that—along with projections—hysterical re-identification also plays a decisive role in projective identification and altruistic surrender, whereby in these latter processes the object identifies himself unconsciously with the contents projected onto him in a hysterical or narcissistic manner.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

Narzisstische Persönlichkeitsstörung

Narcissism is a multifaceted term which encompasses traits of normal personality as well as a specific personality disorder. While much research has been concerned with narcissism as a trait there are only few empirical studies on narcissistic personality disorder (NPS). The current diagnostic system of NPS according to DSM-5 (section II) focuses on grandiose narcissism whereas vulnerable narcissism, which is emphasized by clinicians and researchers, has not yet been recognized. While treating NPD patients an increased suicide risk has to be taken into consideration. Psychotherapy of narcissistic patients mainly focuses on processes during patient-therapist interactions, the analysis and processing of grandiose and vulnerable schemas, emotion regulation techniques and a correction of narcissistic behavior in favor of prosocial interactions.     

Isolation

This paper reflects upon Winnicott’s term “the isolate” or “incommunicado self,” which must remain hidden for personality development to proceed satisfactorily. Paradoxically, the (of necessity) concealed isolate or True Self accedes to the personality’s dependence on an object for this development to take place. The impact of trauma on the isolate and the formation of pathological isolation are considered. The outcome of analysis with a traumatized person is contingent upon the type of narcissistic defenses employed to protect the isolate that has experienced impingement and exposure, with the adverse consequences for personality development this entails. A particular form of narcissistic withdrawal into what Green terms “deobjectalization” and “negative narcissism” is examined as a way in which the death instinct can infuse the personality’s defense of the isolate, limiting radically what may be analyzed. A clinical example is given.     

Group therapy in an outpatient setting with borderline and narcissistic delinquents on probation

DSM-III criteria are used to describe the pathological manifestations of narcissistic and borderline disorders. The former gives rise to the Grandiose Self and the need to control the world. The delinquent act is an attempt to gain such control. The latter demonstrates ego splitting, primitive terror and rage stemming from the failure of the primary maternal introject. The attempt to compensate for inner turmoil and lack of object relatedness leads to delinquent acts. Citing three probationers referred by the court for group therapy, benefits and obstacles encountered in the use of outpatient group therapy are discussed as an approach to solving the unique problems presented by these delinquents.     

Narcissism in the Epistemological Pit

For some people, the move from dualistic to relativistic epistemological thought is accompanied by significant psychological distress. Although there are several possible sources of psychological difficulty in stage transition, we argue that long-standing deficits in object relations can predispose a person to clinical crisis during particular life phase and cognitive stage transitions. Specifically, a person is likely to experience clinical crisis during a particular life phase or stage transition if that developmental advance requires abandoning strategies that have been used to shore up faulty self and object representations. The life phase move from adolescence to adulthood and the cognitive stage shift from dualistic to relativistic thought often pose particular difficulty for persons with a narcissistic personality organization. The epistemological move to relativism can be particularly traumatic when adolescents have cathected their own intellectual products (ideas, ideologies) as idealized self-objects. A case study is presented to illustrate the clinical crisis that can be precipitated by the narcissistic adolescent's loss of intrapsychic supports in the move to adulthood and to committed relativism.     

A narcissistic defence against affects and the illusion of self-sufficiency.

A narcissistic defence against affects, unlike isolation, is a defence against an object relationship. Object relations are strengthened by the sharing of genuine affects so that the failure to share feelings or the presentation of false feelings creates distance between the self and other objects. The defence is similar to that of denial in that it entails a modification of the ego's own structure. We have suggested that this modification consists of a precocious but fragile establishment of a sense of self. The defence may occupy a sector of the personality or reflect a more massive structural arrest. When there is this structural arrest, we believe that this narcissistic defence forms the basis for the narcissistic character disorder described by Kohut and the false self of Winnicott. This precocious sense of self leading to an illusion of self-sufficiency may also be found in other disorders, including the borderline patient, but the borderline patient, in contrast, suffers from a failure of internalization which leads to object hunger in contrast to the denial of object need of the narcissistic disorder. We suspect that the environmental trauma that may contribute to the narcissistic disorder is less severe as compared to the borderline states and may consist of the mother's failure to accept the child's separateness and autonomy, resulting in a fear of the mother's intrusiveness. The fear of the maternal object's intrusiveness contributes to the relative inability to form a therapeutic alliance in the psychoanalysis of narcissistic character disorders. The analyst's interpretations are experienced as dangerous, not necessarily because of their content but due to the fear of the analyst's intrusive influence. Our understanding of the means of effecting therapeutic change must be modified in patients with narcissistic character disorders for, in contrast to the 'classical' neurotic, analytic progress is not obtained by means of interpreting the transference neurosis in the context of a working or therapeutic alliance. Although we acknowledge that the psychoanalysis of narcissistic disorders can lead to significant therapeutic gains, such analyses may prove to be interminable if the gains do not also result in the establishment of a transference neurosis and therapeutic alliance.     

Some psychoanalytical experiences with the new fertility techniques

Abstract

The contingencies in life histories of one male and two female patients of their wish to engage in new techniques for fertility and procreation are explored. Remarkable denial strategies defending narcissistic vulnerabilities were found in all cases. Although they are in fact quite stressful and at best moderately succesful the new medical-technical solutions can acquire magic qualities warding off unresolved conflicts around omnipotence and gender differentiation. In the treatment-process transference undergoes distinct shifts in quality, intensity as well as object when oedipal and pre-oedipal conflicts tend to be acted out with the administering physician. As to the fate of the psychic development of children begotten in these new forms of procreation and parenting, e.g. lesbian couples, much is yet unclear; though complex and fluid defenses coloured by denial and magical qualities towards the father introject have been observed.     

Differential endophenotypic markers of narcissistic and antisocial personality features: A psychophysiological investigation

This study investigated the differential psychophysiological correlates of narcissistic and antisocial personality features in a college student sample. Skin conductance (SC), respiratory sinus arrhythmia (RSA), and pre-ejection period (PEP) were monitored while participants watched a countdown to an aversive noise blast and viewed emotionally valenced slides. Results indicated that narcissistic personality features were unrelated to SC reactivity during the countdown, whereas antisocial personality features were negatively related to SC reactivity. Narcissistic personality features were also related to RSA decreases and PEP shortening while viewing happy slides, whereas antisocial personality features were not. Taken together, these findings suggest differential endophenotypic markers of narcissistic and antisocial personality features despite their clinical similarities.     

Integrative Therapie von narzisstisch gestörten Patienten

The psychotherapy of patients with a narcissistic personality disorder continues to be a psychotherapeutic challenge. There is still no psychotherapeutic program for the treatment of these patients which integrates different psychotherapeutic methods and strategies. Therefore the therapy of narcissistic patients remains difficult and only few psychotherapists voluntarily meet the challenge of treating such patients. In this article an integrative psychotherapeutic concept for the treatment of narcissistic patients using psychotherapeutic methods of different psychotherapeutic schools is presented. This integrative concept includes basic strategies such as working with the therapeutic alliance, schema work and activation of resources. On the other hand specific modules for different core symptoms of these patients are proposed. With this article the authors hope to contribute to a new conceptualization of the psychotherapy of narcissistic patients.     

Orientations of psychotic activity in defensive pathological organizations

The author reviews some clinical experiences of the treatment of personality disordered patients suffering from internal domination of ego functioning by a defensive pathological organization. In particular, the function and purpose of perverse, sadistic attacks by the organization on the ego are considered and questions pertaining to technique are raised. It is suggested that different forms of sadistic, subjugating activity by pathological organizations may denote differences in intent borne of the type and severity of the psychopathology of the individual. Patients with severe narcissistic psychopathology for whom object contact has become associated with the arousal of intense psychotic anxieties seem more likely to be subjected to an invasive, annihilatory imperative by the pathological organization, the purpose of which appears to be to obliterate the experience of contact with any differentiated object, to avoid emotion and to use coercion to enforce a primitive identification by the ego with the psychotic organization in the mind. Certain patients with less severe narcissistic psychopathology, yet for whom object contact can also be associated with the arousal of psychotic anxieties due to intense or persistent conflict with the object, sometimes expressed as organized sadomasochistic clinging to a punishing and punished object (for example, in certain borderline or depressed patients) exhibit sadistic attacks that serve less to annihilate object contact and more to intrusively control and punish the object. Observations of these phenomena have been made by a number of psychoanalysts in recent decades and these contributions are discussed. This paper is addressed primarily to the implications for technique with such patients, particularly a need for triangulation of their experiences of oppression in order to loosen the controls over the ego by the pathological organization.     

Evidence for the criterion validity and clinical utility of the Pathological Narcissism Inventory

In this study, the authors evaluated aspects of criterion validity and clinical utility of the grandiosity and vulnerability components of the Pathological Narcissism Inventory (PNI) using two undergraduate samples (N = 299 and 500). Criterion validity was assessed by evaluating the correlations of narcissistic grandiosity and narcissistic vulnerability with established indices of normal personality traits, psychopathology and clinical concerns, and pathological personality traits. Overall, the pattern of correlations supported the convergent and discriminant validity of grandiose and vulnerable conceptualizations of pathological narcissism as measured by the PNI. Clinical utility was assessed by evaluating the extent to which clinicians without specific training in pathological narcissism as well as clinicians with expertise in pathological narcissism could accurately predict the correlates of PNI grandiosity and vulnerability with normal and pathological personality traits and psychopathology. The r(contrast-cv) coefficient provided a global index of accuracy in clinicians' predictions that was more fully elaborated by examining systematic discrepancies across groups. Overall, novice and expert clinicians were generally able to predict criterion correlations, with some exceptions (e.g., counter to predictions, pathological narcissism was negatively associated with treatment resistance). These results provide further evidence regarding the validity and utility of the narcissistic grandiosity and narcissistic vulnerability constructs as measured by the PNI.     

Adult Attachment Interview and Psychoanalytic Perspective: A Single Case Study

In this single case study we present a female patient diagnosed with a narcissistic personality disorder and a borderline organization. The interplay between attachment and psychoanalytic perspective will be focused. The analyst describes his impressions of the initial interview with the patient and essential steps during treatment. The patient was interviewed with the Adult Attachment Interview and classified as “insecure preoccupied” with an “unresolved state of mind” concerning loss and abuse. The analyst was asked to comment the AAI's essential characteristics of this patient. We discuss converging and diverging aspects of clinical and attachment interpretation in this single case.     

The superego, narcissism and Great Expectations

The author notes that the concepts of the superego and narcissism were linked at conception and that superego pathology may be seen as a determining factor in the formation of a narcissistic disorder; thus an examination of the superego can function as a 'biopsy', indicating the condition of the personality as a whole. Charles Dickens's novel Great Expectations is presented as a penetrating exploration of these themes and it is argued that in Pip, the central character, Dickens provides a perceptive study of the history of a narcissistic condition. Other key figures in the book are understood as superego representations and, as such, integral to the vicissitudes of Pip's development. In particular, the lawyer Jaggers is considered as an illustration of Bion's notion of the 'ego-destructive superego'. In the course of the paper, the author suggests that Great Expectations affirms the psychoanalytic understanding that emotional growth and some recovery from narcissistic difficulties necessarily take place alongside modification of the superego, allowing for responsible knowledge of the state of the object and the possibility of realistic reparation.     

A case of phallic-narcissistic personality

A case of phallic-narcissistic personality is presented to demonstrate the intermingling of oedipal and narcissistic transferences and to suggest a therapeutic rationale for the analytic treatment of similar cases. The therapeutic approach to dealing with the narcissistic configurations involves: Empathic and receptive listening to the patient's material relating to and reflecting narcissistic motifs. This early objective extends only to gaining access to the detailed scope of the narcissistic material in its multiple aspects. Clarifying and identifying the relevant narcissistic configurations, both superior and inferior aspects, so that the patient becomes increasingly aware of their pervasive influence, and increasingly able to identify the respective motifs. Interpretively linking the narcissistically inferior and superior configurations into a common gestalt, so that the patient comes to understand that these opposing aspects are mutually linked, defensively interconnected, and reciprocally reinforcing. Identification and interpretation of interlocking patterns of projection and introjection, particularly as they reflect and express narcissistic configurations. Modification of patterns of projection and introjection through the medium of the ongoing interaction (partly interpretive, partly extra-interpretive) that characterizes the relationship between analyst and patient. Patient projections are thus modified and replaced by more autonomous and adaptive introjections derived from the analytic relation that facilitate the alteration of pathogenic narcissistic formations.     

Interpersonal analysis of grandiose and vulnerable narcissism

This article examines the validity of grandiose and vulnerable subtypes of narcissistic character styles through an analysis of personality disorder criteria, interpersonal problems, and adult attachment styles in a nonclinical population. The grandiose personalities in this sample were rated high in the dramatic traits associated with narcissistic, antisocial, and histrionic personality disorders based on a diagnostic interview, and they reported domineering and vindictive interpersonal problems. However, despite the observation of narcissistic personality pathology, they denied interpersonal distress related to their interpersonal problems and the majority reported adult attachment styles reflective of positive self-representations (Secure, Dismissive). Vulnerable narcissistic individuals were represented by high ratings on avoidant personality disorder based on a diagnostic interview. They reported high interpersonal distress and greater domineering, vindictive, cold, and socially avoidant interpersonal problems. The majority reported adult attachment styles reflective of negative self-representations (Fearful, Preoccupied). The validity of grandiose and vulnerable narcissism based upon the results of this study was discussed in terms of clinical theory and with reference to the implications of two subtypes of narcissism for diagnosis and treatment.     

Psychoanalytische Überlegungen zur Pädophilie

Following the long psychoanalytic tradition in the treatment of paedophiles, in a first step this article tries to define structural components of sexual delinquency that on the one hand correlate with the psychoanalytic model of psychic structures and on the other hand are consistent with the clinical experience of forensic psychotherapeutic practice. In a second step different levels of severity in the structural psychopathology of sexual delinquents are described by taking advantage of the object relationship theoretical conception of personality organisation. Finally, in a third step the psychodynamic features of these patients are highlighted, which have frequently been found and described in the clinical psychoanalytic literature on paedophilia including traumatising mother relationship, narcissistic object choice, inadequate triangulation, self-permuting drive, simulation and disturbance of identification.