The narcissist, unmasked

by Benedict Carey

Behind the confident face is a self-loathing
that therapists are just learning to confront.

They've got the most fabulous personal trainer in town, the best lawyer, the top BMW mechanic, and make sure the world knows it.

They're charming enough to attract friends, associates and lovers -- only to drop them as soon as better prospects show up. They need the best table in the house, the lion's share of the conversation and, above all, top billing, whether on the marquee or in the mailroom.

While familiar at almost any level of society, these peacocks find Southern California an especially comfortable habitat. In the warm bath of sunlight and celebrity, their behavior can be entertaining, even encouraged, and it's usually relatively harmless.

Yet some of these seemingly overconfident people are actually in considerable psychological trouble, suffering what psychiatrists call narcissistic personality disorder, one of the most self-destructive and difficult-to-treat conditions in the lexicon of mental illness.

For contrary to Narcissus of Greek legend, who was enthralled by his own reflection in a pool of water, researchers say that roughly 1 million Americans with this personality disorder act not from self-love but from a kind of self-loathing, a dread of failure and an inability to endure its emotional fallout -- shame.

Millions more are thought to suffer from narcissistic tendencies, due to similar but less extreme fears. Recent research suggests that this anguish develops in early childhood, and that therapists can help put it to rest. New treatments combine advice on handling everyday situations -- so-called cognitive therapy -- with emotional forays into the unconscious more typical of psychoanalysis.

This integration of biology and psychology amounts to a "paradigm shift" in the way that therapists understand conditions such as narcissism, said Allan Schore, a UCLA behavioral specialist and expert on the origins of personality disorders.

"The essential thing seems to be that the patient not only see their narcissism, and talk about it," he said, "but also that they have a physical experience of the emotion that underlies it -- rage, shame, sadness, whatever it is."

Disorder's specific traits

The word "narcissist" is so commonly thrown around that it's in danger of becoming an all-purpose label for any difficult character, in the same way that "chauvinist" or "fascist" was used a generation ago. When psychiatrists diagnose the disorder, however, they do so on the basis of several specific traits.
These include a grandiose sense of self-importance, in which talents and personal achievements are vastly exaggerated; a desperate need for admiration; an almost absolute blindness to the needs and feelings of others; and continual fantasies of power, ideal love and success that far outstrip the ordinariness of many narcissists' lives.

To be sure, when deployed in a business that feeds on self-promotion and star power, such as entertainment or music, these qualities often produce just that: a star, a sensation, the sort of executive or performer who lands in a Brentwood estate with a chef and a fleet of German sports cars.

But add to this carefully cantilevered life some imperfect elements -- a demanding spouse, young kids, sluggish box office or sales -- and you can almost hear the joists creaking.

When deprived of across-the-board success in the outside world, narcissists' need for attention may turn inward, causing depression, mood swings, even exacerbating physical pain, said Marc Schoen, a UCLA School of Medicine psychologist. "And of course their pain is always much, much worse than anyone else's," he said.

Marriages often wither under such selfish complaint. Alcohol and drug problems are commonplace. Usually it's only a matter of time, therapists say, before there's trouble in the arena that's often the most gratifying, work.

"That's when they come to see someone like me," said Dr. Robert Neborsky, a San Diego therapist who specializes in difficult-to-treat patients, some 40% of whom have narcissistic tendencies, if not the whole package, he estimates.

"At some point they look around and realize that at home, and at work, everyone hates them." The narcissistic longing for admiration has brought loathing instead, and they don't know why.

As patients, they're no treat, either. Pompous one moment and solicitous the next, alternately contemptuous and then exuberantly affectionate, narcissists qualify as among the worst therapy candidates on Earth. They may know something is wrong but resist treatment so vigorously because the nature of the disorder is based on self-defense and deception of others -- even a therapist trying to help.

In his description of the condition in 1914, Sigmund Freud declared them all but uncurable. At the first hint of disappointment or challenge they might stalk out of the room. Neborsky has told patients that unless they let down their guard and stop trying to outwit him, there's nothing he can do for them.

One such patient, a 36-year-old Los Angeles rock musician named Jason, returned to Neborsky's office when he found he could no longer bear his own company. Powerful narcissistic impulses had alienated those around him, he said. He was suffering severe bouts of depression.

"I was the type of person who had to be the biggest rock star within 100 miles, and every time I turned on the radio and heard other bands it was just torture," he said. "Partly, it's the business.... The definition of narcissist should say 'lead guitarist.' "

The mask of high self-approval must crack, under the strain of some catastrophe at home or at work, before there's any plea for help, therapists say. It is the new awareness among some therapists that they must be patient and wait for pain to show itself that has helped many of them achieve success.

That reaction does not have to spill out from a welter of childhood memories; it may be connected to something that happened at work the previous week, or even in therapy.

"Often there's a break when the therapist goes on vacation, and isn't around when the person is in need," said Dr. James Grotstein, a psychoanalyst in Los Angeles. "The patient is just outraged to learn that I'm not an extension of him, or her. That's the beginning of an emotional connection."

The hot flush of shame, or anger; the heavy ache of sadness, or loss: These physical sensations themselves, expressed in the presence of a capable therapist, appear to activate areas in the brain that did not develop normally in narcissists' second year of life, said Schore.

Researchers do not know exactly why the development goes awry. Some -- in a revival of what has become an out-of-fashion point of view -- attribute the problem to parents who can't or don't properly soothe their toddler's disappointments: teaching the child, in effect, to avoid failure at all costs, rather than learning to cope with it.

Frozen in childhood?

Other theorists are convinced that parents' indulgence of their child's moods and demands freezes the boy or girl in a state of childlike grandiosity.

Either way, brain imaging studies suggest that deficits in the emotional connection between small children and their mother (or primary caregiver) appear to affect the development of right-brain areas involved in empathy and compassion. Although speculative, this notion is influential in the way some therapists think about narcissism, and places the disorder in the context of some cutting-edge research.

The evidence that a therapist can directly affect these areas of the brain in narcissists is based on studies of similarly difficult conditions, such as obsessive-compulsive disorder. In one recent experiment, for instance, researchers at UCLA did brain scans on obsessive-compulsive patients.

After 10 weeks of talk therapy, the patients improved, and the scans showed significantly reduced activity in a part of the right brain that has been linked to compulsive behavior and personality disorders, including narcissism. In another experiment, Swedish investigators reported in May that therapists induced similar changes in patients with social phobia. The very same principle is at work when narcissists are successfully engaged, Schore argues.

Certainly when an emotional connection is made, against all odds, patients become more open to practical advice they can use to regulate their behavior day to day, psychologists say. A patient learns to spot the destructive pattern as it develops and to defuse it.

"You're talking about the kind of person who might be standing in the checkout line, and suddenly have a flash of disrespect, a real hurt, because he doesn't feel he's being waited on properly--and now wants to punish someone for that," said Judith Beck, director of the Beck Institute for Cognitive Therapy and Research in suburban Philadelphia.

One of Beck's recent patients, a retired corporate executive, was so accustomed to star treatment at work and at home that he became furious whenever he was treated normally, whether at the dry cleaner or library checkout counter. Before attending social events the man would prepare himself to be preemptively nasty toward strangers he assumed would not appreciate his specialness.

Beck had him trade those put-downs for questions: What kind of work do you do? How did you get involved in that area? "He was flabbergasted at the response," Beck said. "No one attacked him; people reacted very positively. This went a long way in changing his idea that he had to always be on guard."

Techniques like this also can help narcissists avoid outbursts at friends or family members, psychologists say. When it comes to romantic relationships in particular, many patients consider their spouse or partner as an extension of themselves, there to provide admiration and support and nothing else, said Marion Solomon, a Westwood therapist whose 1992 book "Narcissism and Intimacy" discusses techniques for resolving narcissism in couples therapy.

"Sometimes all it takes is for the wife to be late to a dinner party," she said, "and now he's yelling at her, 'How could you do this to me?'

"For the true narcissist there's no acknowledgment that this is a separate person, with their own needs and thoughts and desires. Just getting a patient to see that can make a difference in a relationship."

October 14 2002 / Copyright 2002 Los Angeles Times