1. Battaglia M. Dialogues Clin Neurosci 2015;17:277-85. 9. Manicavasagar V, Silove D, Wagner R et al. Compr Psychiatry 2003;44:146-53.

2. Bowlby J. J Child Psychol Psychiatry 1960;1:251-69. 10. Pini S, Abelli M, Shear K et al. Acta Psychiatr Scand 2010;122:40-6.
3. Mikulincer M, Shaver PR. Curr Opin Psychol 2015;1:18-21. 11. Silove DM, Marnane CL, Wagner R et al. BMC Psychiatry 2010;10:21.
4. Bowlby J. Attachment and loss, Vol. 2. New York: Basic Books, 1999/1973. 12. Silove D, Alonso J, Bromet E et al. Am J Psychiatry 2015;172:647-56.
5. Gittelman R, Klein DF. Psychopathology 1984;17:56-65. 13. Milrod B. Am J Psychiatry 2015;172:601-2.
6. D’Amato FR, Zanettini C, Lampis V et al. PLoS One 2011;6:e18637. 14. Pini S, Abelli M, Mauri M et al. Bipolar Disord 2005;7:370-6.
7. Roberson-Nay R, Eaves LJ, Hettema et al. Depress Anxiety 2012;29:320-7.
8. Kossowsky J, Pfaltz MC, Schneider S et al. Am J Psychiatry 2013;170:768-
DOI:10.1002/wps.20336
81.

The many faces of narcissism

Although the term narcissism is widely used in psychiatric narcissistic personality disorder than in the age group over 65.
discourse, there is much confusion about its precise meaning. However, we must question the idea that the current genera-
The term is most often used pejoratively to refer to someone tion is developing such a vastly higher number of narcissists.
with excessive vanity or an urgent need for validation and praise. The overlap between cultural shifts and individual pathology
There is a continuum of narcissism, and the point where healthy must be more complex than simply following a list of diagnos-
self-esteem ends and pathological narcissism begins is highly tic criteria. Moreover, the constant connection to social media
arbitrary. A further complication is that some individuals who has also led to altruism in this new generation. Indeed, they
have elements of pathological narcissism may have sectors of are dedicated to service projects, are socially aware and con-
their personalities that are characterized by generosity towards tribute to charity at a higher rate than their elders6. Not only
others. do we need to consider the false dialectic between narcissism
It is unfortunate that a false dialectic between narcissism and and altruism in individuals; we must also consider it more
altruism is in common usage. The two entities regularly co- broadly in the culture.
exist. Vaillant1, in his longitudinal study of healthy males, found In the midst of this confusion, how do we distinguish healthy
that altruism increases significantly in the second half of life – self-interest from pathological narcissism, usually referred to as
not simply because we become more selfless as we age, but narcissistic personality disorder? The time-honored indices of
rather because helping others becomes more rewarding to us. A “to love and to work” are problematic in this context, because
neuroimaging study2 demonstrated that those who are altruistic some of the most successful individuals from an economic per-
directly benefit from their altruism. Participants had to choose spective are also highly narcissistic7. Their narcissistic need for
to endorse or oppose societal causes by anonymous decisions acclaim and recognition may motivate them to succeed. On the
to donate or refrain from donating to real charitable organiza- other hand, the capacity for mutuality and reciprocity in love
tions. The mesolimbic reward system was engaged when one relationships may be useful in identifying narcissistic personali-
donated money in the same way as it was when one received ty disorder. Others are often used up and discarded, existing
monetary awards. In other words, altruism activates brain cen- only to serve the narcissistic individual’s needs.
ters that are associated with selfish pleasures like sex or eating. While problems in human relatedness are central to nar-
A further complication is that the term narcissism is used as cissistic personality disorder, clinicians must be alert to the
a clinical entity as well as a way of denoting cultural trends, as fact that narcissistic individuals may have considerable vari-
in C. Lasch’s book The Culture of Narcissism3, describing a cul- ability in their ways of relating to others. There is a spectrum
tural phenomenon in the 1970s in which the growing role of the of narcissistic personality disorder, not necessarily reflected
media promoted a lack of substance and depth in the culture. in the official nomenclature. Psychoanalytic debates about
In our decade, we are in the midst of another cultural awaken- narcissistic patients stemmed from differences noted by
ing as the constant interaction with technology and social Kohut8 and Kernberg9. While Kohut’s formulation was based
media is impacting the cultural perspective of the self. Members on a self-deficit model, causing patients to be highly sensitive
of the millennial generation live in a constantly connected, tech- to narcissistic injury, Kernberg emphasized the aggressive
nologically visible, self-oriented public space. Time captured and destructive aspects of these patients. Further research
this cultural moment by referring to the “Me Me Me Gener- has documented the existence of two subtypes of narcissistic
ation”. S. Turkle4 described how the smartphone generation is personality disorder: the grandiose and oblivious variant and
populated by people who are losing the art of human interac- the hypervigilant or fragile subtype7. More recent research10
tion. A radical new self is emerging, one that is shaped by what detected a further high-functioning variant, which is outgo-
we want others to see. One can receive validation, praise and ing, energetic and articulate, with an exaggerated sense of
self-esteem enhancement within seconds after pressing “send” self-importance.
or posting a “selfie”. The fact that narcissistic personality disorder is not a mono-
In a study by Stinson et al5, there were nearly three times lithic entity creates challenges for the diagnostician and the
the number of persons in their twenties meeting criteria for psychotherapist. In keeping with the notion that the key to

World Psychiatry 15:2 - June 2016 115

diagnosis lies in the quality of love relationships, we suggest Narcissistic patients may feel understood if the clinician
that a careful examination of modes of relatedness is crucial7. focuses on self-esteem struggles and vulnerability beneath the
As Kohut stressed, some patients who are narcissistically orga- grandiose surface. Some patients may not be able to tolerate
nized tend to idealize others so that they can bask in the any confrontation at first, and may need long periods of
reflected glory of an idealized object. They may insist on the empathic validation in order to preserve a therapeutic alliance.
most famous psychotherapist or pick a romantic partner purely A subset of these hypervigilant patients may never be able to
on his/her looks so that others will be impressed. tolerate confrontation or rupture, and may instead use the
Denial of the romantic partner’s autonomy may be a central treatment over months and years to shore up a shaky sense of
strategy for some narcissists. They are wounded if their love self-esteem and build validation. Timing is everything in mak-
object acts or thinks independently. The fantasy of control serves ing an impact through interventions, and it is advisable to wait
to defend against ongoing anxiety of losing the one they love. for openings in which the patient lets the therapist know that
However, it also represents a common problem with narcissistic he or she is hurting and yearning for help.
individuals – namely, they cannot mentalize the internal experi- The psychiatrist must be attentive to countertransference
ence of the other. Hence, they are unable to empathize with the issues. Kernberg9 described that the therapist can feel con-
partner’s need for agency, autonomy, and freedom from control. signed to a “satellite existence”, which can lead to boredom and
Another common mode of relatedness is to deny all pain or con- distance impacting the therapy. In addition, therapists must be
flict in the love relationship, thus turning away from reality. alert to contempt and enactments of judgment and criticism.
Narcissistic patients are desperately attempting to manage Finally, patients with narcissistic problems can require some of
their vulnerability. Hence denial of dependency, sometimes the longest treatments in a therapist’s caseload. Consultation is
referred to as “pseudo-self-sufficiency”, is another strategy in recommended in conflicted or difficult cases.
their repertoire. If they do not need anyone, then they cannot be
hurt by losing someone. Another way that narcissistic individu-
Glen O. Gabbard, Holly Crisp-Han
als will relate to love objects is to see the other as completing the Department of Psychiatry, Baylor College of Medicine, Houston, TX, USA
self. It is as though there is a “hole” in their sense of self that
requires another person to perform missing functions for them. 1. Vaillant GE. Aging well: surprising guideposts to a happier life from the
A common form of this occurs in patients who cannot soothe Landmark Harvard Study of Adult Development. Boston: Little, Brown and
Company, 2003.
themselves and need their romantic partner to comfort them, 2. Moll J, Krueger F, Zahn R et al. Proc Natl Acad Sci 2006;103:15623-8.
tell them they are wonderful, and provide empathy for their 3. Lasch C. The culture of narcissism: American life in an age of diminishing
pain. The relationship may end when the partner is not consis- expectations. New York: Norton, 1979.
4. Turkle S. Alone together: why we expect more from technology and less
tently providing the admiration or praise the patient requires. from each other. New York: Basic Books, 2011.
Narcissism is pervasive in its normal and pathological vari- 5. Stinson FS, Dawson DA, Goldstein RB et al. J Clin Psychiatry 2008;69:
ants. While some presentations are quickly apparent in treat- 1033-45.
6. Kristof N. A millennial named Bush. New York Times, July 26, 2015.
ment, as in the oblivious subtype, others may take longer to 7. Caligor E, Levy KN, Yeomans FE. Am J Psychiatry 2015;172:415-22.
manifest in the clinical relationship. A person with the high 8. Kohut H. The analysis of the self. Madison: International Universities
functioning variant, who presents with energy, gregariousness Press, 1971.
9. Kernberg OF. Borderline conditions and pathological narcissism. North-
and self-importance, may be initially charming to the psychia- vale: Aronson, 1975.
trist and hence it takes longer to detect clinically significant 10. Russ E, Shedler J, Bradley R et al. Am J Psychiatry 2008;165:1473-81.
narcissism. Only over time does the lack of relatedness and
low self-esteem become clear. DOI:10.1002/wps.20323

Time for a global commission on mental health institutions

Concerns about institutional care of people with mental dis- people with mental disorders in such institutions, there is cur-
orders are no longer as prominent as they once were. This is rently little interest in what is happening in those hospitals and
understandable in light of deinstitutionalization and the closure other facilities in which people with severe and persistent men-
of many psychiatric hospitals in much of the Western world. tal disorders are treated and sometimes confined.
However, this neglect of old concerns is not excusable. Custodi- To a great extent, the field of global mental health has rele-
al mental hospitals which are, either directly or indirectly, the gated the exposure of abuses in mental hospitals and other
legacy of colonial psychiatry remain in many low- and middle- institutions to news media1, non-governmental organizations2,
income countries the dominant, if not the only, component of and human rights commissions3. Hospitals and other institu-
national mental health systems. It is puzzling therefore that, tions are not mentioned in any of the top 25 Grand Challenges
despite the increasing attention to global mental health and the in Global Mental Health4, although that paper includes a pho-
increasing familiarity with the unsatisfactory circumstances of to of women in a psychiatric hospital in Ukraine.

116 World Psychiatry 15:2 - June 2016