THE CONCEPT OF NARCISSISM IN PSYCHOSIS AND IN SEVERE PERSONALITY DISORDERS

Abstract

The concept of narcissism has a certain connotation in psychiatry and a slightly different one in psychoanalysis. This is similar to the concept's evolution, over the years, undergoing major changes, defining varied psychodynamic or psychological realities. Therefore, this paper proposes a multi-faceted perspective on the concept of narcissism, from the perspective of multiple psychoanalyst authors belonging to various currents /orientations. The overall objective is to demonstrate that: narcissism involves a particular way of mental functioning, having roots in childhood and in early relational models, but that, in time, a particular type of functioning determines a structure of some kind (of organizing the personality), which can be correspondent to the wide array of enhanced features or to a severe psychiatric diagnosis. [PUBLICATION ABSTRACT]

Headnote

Abstract: The concept of narcissism has a certain connotation in psychiatry and a slightly different one in psychoanalysis. This is similar to the concept's evolution, over the years, undergoing major changes, defining varied psychodynamic or psychological realities. Therefore, this paper proposes a multi-faceted perspective on the concept of narcissism, from the perspective of multiple psychoanalyst authors belonging to various currents /orientations. The overall objective is to demonstrate that: narcissism involves a particular way of mental functioning, having roots in childhood and in early relational models, but that, in time, a particular type of functioning determines a structure of some kind (of organizing the personality), which can be correspondent to the wide array of enhanced features or to a severe psychiatric diagnosis.

Keywords: narcissism, psychodynamic psychiatry, mental functioning, psychiatric diagnoses, disorders.

The narcissist identification, along with self-accusations, is specific to melancholia. The aggressive impulses towards the parents are initially suppressed. In depression with psychotic elements what is happening is the delirious awaiting of the punishment1. The mourning is the disinvestment of the object, bearing the idea that testing reality shows that, what you loved, does not exist anymore. In depression with psychotic elements this is a form of hallucinatory maintenance of the object2. Normalcy means the respect in the face of reality. The mourning of a relationship is done similarly. The libido retracted from the object remains in the ego. At the opposite, mania is omnipotent above things.

Schizophrenia. In psychoanalysis the problem is that of conflict versus deficit. Catexis represents the amount of energy attached to any intra-psychic structure or any object; it is a libidinal investment. From this point of view, schizophrenia involves decathexisation. Freud saw schizophrenia as a regression in the relation to an object towards an autoerotic stage of development, as a response to intense frustration that leads to an autistic isolation and the reinvestment of the cathexis within the Self or the Ego. If neurosis was a conflict between Ego and Self, psychosis is a conflict between Ego and the outside world. The question is to what extent a schizophrenic patient can develop a transfer.

Sullivan talks about the parent - child relationship as of a long interpersonal process3. A difficult maternity stage would lead to an anxious, suffering Self, a dissociated Self, with a dissociated self - esteem, although the need of relating remains present. Frieda Fromm believes that schizophrenia patients are not happy with this state. They are alone and they do not overcome their fear and distrust in others. Irregularities in ego boundaries make the outside - inside barrier disappear, the border is not psychologically invested anymore.

Margaret Mahler believes that this boundary is established from the first mother - baby contacts, for this problem there is the following difference: their own Self / the others'4 Self. Psychological merging to / with others reproduces the primary relationships, while symbiotic merging produces, as well, a huge anxiety. One such patient perceives you as a function belonging to him/her, not as a separate person. This occurs as well in all his / hers' relationships. The conflict - defense model goes along in schizophrenia, but the quantitatively aspect differs. Specifically it would be: more severe regressions, more intense difficulties linked to aggression and acuter problems of the Self and Super - Self functioning. That makes these patients have a greatly increased transfer contrasting with their isolation. Symbolically, "they are holding on to you" and their request is being explicit.

Hallucinations are desires projected in phantasms which are the same as reality. Delirium is the phantasmatic working of their desires and their fears [arrow right] the sensitive relationship delirium5. Hypersensitivity to perceptual stimuli belongs to the biological. To cope with these, patients use splitting and projective identification mechanisms = expel the bad, like the baby refusing bad milk. The autistic unacceptability of the schizophrenic results from the conflict between what is proper and the absorption of external thoughts and feelings. The schizophrenic is unable to contain his / her emotions, feelings and thoughts, in this regard the metaphorical house that has everything you need, but things are disordered is suggestive. The functioning and disposition of these things is incongruent.

Solving can occur as follows:

- Expulsion of thoughts regarding the mother, sister, or someone else = projective identification

- Fragmentation and distortion of thought = formal, vague thinking

- Divesting the symbolic cognition of its entire significance = concrete thinking (verbalization number decreases, nouns prevail; conjunctions are eliminated, and so on).

In 1992, Robins takes up the idea of Melanie Klein6, according to whom in the neurosis the Ego listens to reality and in psychosis there is a rift between Ego and reality. It is a protection mechanism and is linked to unassumed homosexuality (when passing over an object similar to itself).

In paranoid schizophrenia, what occurs is the cleavage of the object in good and evil, resembling childhood where the mother who feeds the baby is the good object and the one who's missing is the bad object. The object is cleaved, it cannot reunite the two sides, leading to the idealization with omnipotence or, contrary, to persecution. In the case of aggressive pulse or persecutory anxiety, what is happening is an outside / inside confusion.

In depression the good object's introjection, which becomes the total object, predominates, thus decreasing the division between good and evil7. Libidinal and hostile impulses relate to this object. Restlessness can be combated through manic defenses. With such a patient is less important to interpret, as much as to contain.

A borderline patient is a patient with an unorganized structure, with strong traumas. You can fix something and prevent a worsening. If you contain some of his / her certain parts, you can prevent falling into psychosis.

In post-traumatic stress disorder there are two attitudes: either denial or flash-backs that would require processing and organization of stimuli. Exploratory psychotherapy as trauma reinstatement act is risky.

Narcissism. Freud talked about a primary narcissism that would be an early stage in which all the libido is pulled back over the Self. There is also a secondary narcissism, in which they talk about the return of libido withdrawn from the objected investments.

The Schreber case is a case of paranoia, which clearly highlights narcissistic and psychotic pathology8. Narcissism is a stage between auto - eroticism and love of object. For Freud, psychosis is narcissistic neurosis and presupposes investing the Ego. Abraham calls it early dementia. The idea of the article "Mourning and melancholia" is that narcissism is not a lack of relations, but is a relation chosen after the narcissistic model. There is a non-objective narcissistic state in which there is no I or Self, it is a state which may be reproduced in sleep. It resembles the child's faith in the almightiness of his own thoughts. The primary state previous to the Ego's constitution reproduces the intra-uterine life. The love for a child can be a narcissistic love. Melanie Kleine talks about narcissistic states as about returns of the libido on internalized objects.

Empathy is how the mother gets to know the child's needs. The same happens in therapy with narcissistic issues (deep, pre-oedipal, pre- genital). Kohut rests on the theory of Self - objects = to use external objects for the gratification of internal needs9. The surrounding people become Self - objects for their own Self. This theory started from the one on Ego functioning. Self = I + Self = the personality = psyche = more than the Ego = the Ego + everything surrounding (all the relationships, all the projections) = a whole, which is completely interactive and in which the Self has an instance that surpasses it. It appears to be similar to "Das Seine" of the existentialists. Kohut sees the problems related to narcissism (the Self), not to the Ego, as Freud.

From this perspective, it is important to establish the fact that narcissism does not disappear, but evolves during the entire life. And this is something different from the pathological regression. Stages do not end and others follow, it is a narcissistic line that evolves throughout the whole existence. The Self - objected needs remain! Important is how much the person in question is able to find his / her Self - objects.

There are two poles: one belonging to ambitions (derived from the grandiose Self) and belonging to ideals (derived from parental imago). Between these poles there is a tension, a voltage difference, symbolically put: "pushed by ambition, guided by ideals". Fragmentation of Self (reaching maximum peeks in psychosis) sends to a very archaic level, in which we find physical and mental Self, with the loss of archaic objects. Narcissism means libidinal investment of self. Narcissistic stage is different, is a line of development. Satisfaction can come from narcissism = joyfulness (joy libido) or objective relationship = voluptuousness (pleasure libido).

Grandiose self suggests omnipotent and is tied by the poles of ambitions = recreating a perfect Self, while evil must be expelled, must be eliminated towards outside. The pleasure-Self is reached, purified, from a Freudian perspective. Idealized parental imago aims to restore perfect maternity care. Initially, the child perceives the object as separate, but as belonging to him or to his or psyche. Object assures continuity of Self. The first relationship has a narcissistic function, except a relationship with an object. We obtain a Self - undifferentiated object relationship.

If the object of Self does no longer fulfills the function well, narcissistic problems in development will occur. Whole life persists around the need of Self - objects! A Self - object is not love, it is not perceptible only when it's missing. An object can be hated or loved. The Self - object is a necessary form of intra-psychic experience, in normal adults.

Winnicott spoke of optimal frustration, because if application provides everything before internalization transmutation occurs, the existence of the cause is merged10. What fluctuates is the merging. Winnicott talks about disillusionment of the child. Internalized transmutation means the occurrence of mental functions, due to the fact that there is no need for Self - objects anymore.

Narcissistic rage is a reaction to narcissistic injury. Hence the need for revenge against ridicule, the shame used as an aggressive counterpart. It is targeted to restore absolute power to the grandiose self. Narcissistic personality disorder poles are narcissistic wounds (depreciation, shame) and grandiosity.

Gabbard, referring to personality disorders11, talks about good narcissism = feeling good within yourself = to be happy = healthy self- esteem = "fantasy of eternal youth", "how to get success", "how to be number one", "extreme sports". Kohut speaks about vulnerable narcissist, sensitive one, less aggressive when blaming himself, while Kernberg speaks of narcissist's envy and need to hear the others praise him12. On this line, Don Juan's character goes quickly from idealization to devaluation.

Borderline personality (a type of personality organization, not necessarily pathological) - Kernberg 1975:

- Non-specific manifestations of ego weaknesses = no tolerance of anxiety, lack of impulse control, lack of development of channels of sublimation.

- Return to primary thinking processes in which those concerned are exclusively merging with objects = mechanism like "I wish ... I get ..."

- Specific defensive operations: splitting (cleavage), primitive idealization, early forms of projection (projective identification), denial, omnipotence and devaluation. All these are primitive defense mechanisms.

- Pathological internalized object relations.

Margaret Mahler, in 1960, says that these patients were able to cross the symbiotic phase, but were fixed under the rapprochement phase = closeness - farness (of the separation - individuation phase) the child begins to walk and goes away from the mother. The mother is disappointed that he managed to separate himself and makes mistakes in how she welcomes him back when he returns (between 16 and 30 months). The child feels the fear of the emergence - the disappearance of his mother.

A borderline patient will systematically relive early abandonment and will have an inability to tolerate loneliness. At the major separation from parents, anxiety is overwhelming because there are disturbances in the mother's emotional availability: either maternal problems (she did not want children) or has an increased aggression, manifested through the questions "Why do you cry, already!!? What's the matter with you?!!" There is no constancy in the object. There is no integration of the good - bad object in itself and in the mother. But cleavage remains: entirely bad - entirely good, life is either very bad or very good. Negative introjection prevails and there is an increased excess in verbal aggression13.

An overwhelming evil can destroy all that is good in this patient. Aggression is innate14. He does not experience the oedipal complex fully, or he lives it unrefined, almost primitively. He quickly experiences psychotic episodes (with or without drugs) and do not require high doses to calm down.

In therapy:

- these patients have increased anxiety;

- show aggression, hetero-aggression;

- are acting - out - frequently;

- idealize the therapist;

- will merge with the therapist, but are afraid that it will destroy the symbiosis;

- this leads toself - devaluation and feeling of worthiness;

- self-harm, penalty for not meeting expectations of their parents;

- quickly alternating their provisions;

- abusing drugs and alcohol.

Footnote

1 See: *** - Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition. Washington: American Psychiatric Association, 2000.

2 See: ***, Psychodynamic Operationalized Diagnostic OPD-2, Bucharest: Trei Publishing House.

3 Sullivan, H.S., The Interpersonal Theory of Psychiatry, Routledge, Social Science, 2001, The 2nd Part, The 8th Chapter.

4 See: Mahler, S., Pine, M.M. and F., Bergman, A., The Psychological Birth of the Human Infant, Basic Books, New York, 1973, The 2nd Part, The 4th Chapter.

5 See: La z a rescu, M., Clinical Psychopathology, Timis oara: Helicon Publishing House, 1993.

6 See: Klein, M., Heimann, P., Isaacs, S. and Rivière, J., Developments in Psychoanalysis. Karnac Maresfield Reprints, 1985, 1st Part, The 2nd Chapter.

7 Kohut, H., The Analysis of the Self, Madison, 1971, p. 37 - 45.

8 Freud, S., Recommendations to Physicians Practicing Psycho-Analysis. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, p. 198.

9 Kohut, H., op.cit., p.37-45.

10 Winnicott, D.W., The Child and the Outside World, Tavistock, London, 1957, p. 111 - 116.

11 See: Gabbard, G.O., Treaty of Psychodynamic Psychiatry: Bucharest: Trei Publishing House, 2007, The 2nd Chapter.

12 Kernberg, O., Borderline conditions and pathological narcissism, Jason Aronson, New York 1975, p. 86.

13 Trifu, S., Petcu, C., Clinical Cases of Psychiatry. Complex Psychodynamic and Psychological Explanations, Bucharest: University Publishing House, 2011, p. 41 - 46.

14 See: Predescu, V., Psychiatry 1st Vol., Bucharest: Medical Publishing House, 1989.

References

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