Mirror, Mirror on the Wall: Reecting on Narcissism

Donna S. Bender
University of Arizona
This article introduces a special issue of the Journal of Clinical Psychology: In Session focused on the conceptualization and treatment of narcissism. Obscured by an ongoing debate about how best to dene pathological narcissism, clinicians have often lost sight of the fact that narcissistic investment in the self is a normal developmental trend that can be disturbed to varying degrees by environmental stresses and failures of nurturing. Using case presentations, contributing authors demonstrate the following: the importance of understanding the closely interrelated grandiosity and vulnerability associated with narcissistic difculties; variation in the expression of narcissistic types; the role of perfectionism and sadomasochism; and the possibility that narcissistic issues are present across all types of personality psychopathology. Specic alliance-building recommendations are offered, and the greater utility of dening narcissism dimensionally rather than categorically is explored. A clinical case in the current article illustrates each of these central ideas. Together, the discussions presented in this issue invite greater insight into, and appreciation of, narcissistic phenomena, along with examples of effective and empathic treatment approaches. C 2012 Wiley Periodicals, Inc. J. Clin. Psychol: In Session 68:877885, 2012. Keywords: narcissism; narcissistic personality disorder; narcissism dimension; personality psychopathology

It is highly unlikely that a compliment is intended when one is called a narcissist. Individuals with narcissistic difculties are typically viewed as primarily arrogant, condescending, and selfcentered, and often invoke dread and disdain in many mental health professionals, thus impeding effective and compassionate treatment. As Bach (1985) has noted: Our professional literature has often enough tended to characterize patients suffering from narcissistic disorders as grandiose, exhibitionistic, preoccupied with fantasies of power, envious, unempathic, coolly indifferent or intensely enraged, or behaving as if entitled to special privileges. Although many of these traits are without doubt objectively present, such descriptions tend to slight the subjective suffering and other complementary features which would round out the picture and help us from either disparaging or idealizing this particular character type which, in its very description, already suggests the specic countertransference reactions it so frequently elicits. (p. ix) In this issue of the Journal of Clinical Psychology: In Session, experts explore the nature of narcissism and discuss how to recognize and treat narcissistic difculties in clinical practice. Before briey summarizing central ideas discussed by the contributing authors and then illustrating them using a clinical case example, I would like to address several salient contemporary issues regarding narcissism:

There Is No Universal Consensus on the Denition of Narcissism or Narcissistic Psychopathology

What is narcissism? This has proven to be a thorny issue with insufcient empirical inquiry to clear up the dilemma. The main psychiatric approach is captured in the Diagnostic and Statistical
Please address correspondence to: Donna S. Bender, 4031 E. Sunrise Drive, Suite 101, Tucson, AZ. E-mail: bender.donna@gmail.com
C 2012 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 68(8), 877885 (2012) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21892

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Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), which represents the concept as narcissistic personality disorder [NPD], identied by the presence of grandiose self-importance, fantasies of unlimited power, belief in ones specialness, a requirement for excessive admiration, entitlement, exploitativeness, lack of empathy, envy, and arrogance. This portrait seems to t with Bachs aforementioned assessment that this characterization in itself represents negative reactions of the mental health community to certain types of individuals. The proposal for DSM-5 offers a dimensional alternative for assessing narcissism using the Levels of Personality Functioning Scale (Bender, Morey, & Skodol, 2011) that examines self-functioning in the areas of identity and self-direction and interpersonal relatedness represented by empathy and intimacy. Assigning a full-edged NPD diagnosis requires both the consideration of self and interpersonal functioning, as well as the extent to which the personality traits such as grandiosity and attention seeking are present. Academic psychologists have been working on several empirical models of narcissism. For instance, the Narcissistic Personality Inventory (NPI) has identied the following dimensional subscales as indicators of narcissism: authority, self-sufciency, superiority, exhibitionism, exploitativeness, vanity, and entitlement (Foster & Campbell, 2007). Another example is the Pathological Narcissism Inventory (PNI), which includes seven scales: exploitativeness, grandiose fantasy, self-sacricing self-enhancement, contingent self-esteem, hiding the self, devaluing, and entitlement rage (Pincus et al., 2009). The PNI attempts to go beyond the NPI in capturing some of the underlying vulnerability that drives the more unpleasant interpersonal manifestations. Of all psychological models, psychoanalysis has been perhaps the most rich in its theoretical and clinical characterizations of narcissism, but as Auerbach (1990) noted: Of the many concepts that Freud bequeathed us, few have proved as elusive as narcissism (p. 545). Examples of psychoanalytic theories of narcissism will be discussed below. As a counterpoint to the DSM, the psychoanalytic community developed the Psychodynamic Diagnostic Manual (PDM Task Force, 2006), which includes an outline for identifying two NPD subtypes: arrogant/entitled and depressed/depleted. In this scheme, clinicians assess the ination or deation of self-esteem, the pervasiveness of shame, contempt and envy, pathogenic beliefs about perfectionism of self and others, and core defenses of idealization and devaluation. Although there is some overlap among the psychiatric, trait psychology, and psychoanalytic models, considerable variation exists as well.

It Is Frequently Overlooked That Narcissism Can Be Healthy and Begins as a Normal Part of Human Development
Given the varying ways of labeling and parsing pathological narcissism, let us not forget the healthy roots of narcissism. Freud (1914/1957) proposed that all infants begin life oriented instinctually toward the self, a psychological developmental phase called primary narcissism, paralleling the need for self-preservation. If a child is properly cared for and the environment does not place excessive and disruptive demands on her or him, from primary narcissism will emerge the capacity for love and interest in others. The early phase of narcissistic investment exclusively in the self is necessary for the eventual differentiation and consolidation of a stable and effective identity, the formation of a mature personality, and the capacity to participate effectively in the world with creativity and positive self-regard. More recently, Kohut (1977, 1984) has expanded upon the theory and treatment of narcissism and proposed that the self can be viewed as a system that organizes subjective experience and is the center of personality. Like Freud, Kohut regarded early narcissistic investment in the selffullling needs for grandiose self-expression and self-promotion as a normal part of development. Kohut proposed that from this early narcissism, grandiosity is eventually modulated and integrated into a cohesive and coherent self-structure with a meaningful identity and self-actualizationthe ability to reach ones potential by setting realistic goals and utilizing ones abilities. Healthy narcissism and the consolidation of the self arises within the matrix of child caregiver interactions and is predicated upon the childs internal experiences and behavioral strivings being adequately received, appreciated, and empathically communicated back (Kohut, 1977).

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Narcissism Likely Does Not Exist Solely as an Either/or Diagnosis, But May Be Better Represented Dimensionally
The consideration of narcissism as a phenomenon integral to normal psychological development is key to one of the controversies that will be taken up by several of the authors contributing to this In Session: namely, whether narcissism exists on a dimension or dimensions ranging from normal through various degrees of pathological severity. Narcissistic impairment dened as the diagnostic category called NPD was ofcially introduced in 1980 in the DSM-III (APA, 1980). This subsequently encouraged clinicians to treat narcissism as a discrete pathological entity: either you have it or you dont. However, many clinicians and social and personality psychologists have considered narcissism to exist on a continuum like most other personality traits. To address the categorical versus dimensional debate, Foster and Campbell (2007) conducted research using the NPI to study the latent structure of narcissism. Nearly 4,000 participants were assessed and the results showed that components of narcissism such as authority, self-sufciency, and superiority were distributed along a continuum with no apparent cutoff point that sharply distinguished normal from pathological. These ndings are consistent with the consensus reached at an international conference convened by the APA to consider salient issues for the upcoming DSM-5. That is, experts on personality disorders were brought together to consider core concerns related to personality disorders in DSM-IV, such as excessive comorbidity among personality disorder diagnoses, and it was determined that all personality disorders, including NPD, might better be dened in dimensional terms (Widiger, Simonsen, Krueger, Livesley, & Verheul, 2005).

Pathological Narcissism Is a Fairly Common Phenomenon and May Be on the Rise in the United States
Having established the premise that narcissism has a normal or healthy basis in the hopes that it might help to assuage some of the negative bias associated with the term, we must necessarily return to the reality that there are pathological levels of narcissism that cause subjective suffering and impairments in self and interpersonal functioning. Furthermore, it seems as if narcissistic pathology is fairly common. Using the strict denition of meeting criteria for NPD, estimates of the prevalence of NPD are as high as 6.2% in community samples (Dhawan et al., 2010) and may be present in up to 35.7% of clinical populations (Zimmerman, Rothschild, & Chelminski, 2005). If we agree that narcissistic pathology occurs in degrees and congurations divergent from the DSM-IV yes-or-no standard, then it is likely we would nd even higher levels present in the current population. Moreover, there has been a growing sense that pathological narcissism is on the rise. Decades before the prominence of tweeting, texting, Facebook, and the advent of the era of reality TV, Christopher Lasch (1979) wrote the Culture of Narcissism, contending that social and economic conditions in the United States had shifted such that the culture of competitive individualism, which in its decadence has carried the logic of individualism to the extreme of war against all, the pursuit of happiness to the dead end of a narcissistic preoccupation with the self (p. xv). Although there has yet to be a denitive study supporting the contention that narcissism is on the rise, there are data indicating that NPD is more prevalent among younger adults in the United States (Stinson et al., 2008).

Rather Than Occurring as Some Inherent Personal Moral Failure, Narcissistic Disturbance Arises From Within a Societal and Familial Context
In his critique of modern American culture, Lasch (1979) maintained that signicant changes in economic and social relationships have led to shifts in the role and dynamics of the family. One aspect is the collapse of parental authority, leading to permissiveness that, rather than making children feel better about themselves, has generated a more primitive conscience dominated by constant critical self-attacks. At the same time, basic emotional needs go unsatised, and a sense of entitlement seems to be increasingly common in younger people.

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Extending his developmental model of normal narcissism referred to above, Kohut (1977) argued that inadequacies in early caresignicant empathic failureslead to a fundamental decit in the ability to regulate self-esteem without resorting to omnipotent strategies of overcompensation or overreliance on admiration by others. Some people who are narcissistically vulnerable have difculty maintaining a cohesive sense of self because of ubiquitous shame, resulting from the conclusion that they fundamentally fall short of some internal ideal. They look for constant reinforcement from others to bolster their fragile self-images. This perspective emphasizes the vulnerabilities that are associated with disturbed narcissism. Kernberg (1984) identied the roots of pathological narcissism as an attempt to survive with parents who were rejecting and devaluing, or who used the child to satisfy their own needs. In order to cope, the child retreats into self-grandiosity without assistance in evolving away from that type of self-concept. The result is manifested in adults who are intensely grandiose, seeking to maintain self-esteem through omnipotent fantasies and defeating others. They defend against needing others by maintaining fusions of ideal self, ideal other, and actual self-images. Thus, there is an illusion maintained whereby this manifestation of narcissism is associated with a sense that because he or she is perfect, love and admiration will be received from other ideal people, and thus there is no need to associate with inferiors. In its most extreme form, this pattern of character pathology has been referred to as malignant narcissism (Kernberg, 1984). The perspectives of Kohut and Kernberg combine to support the idea that narcissistic vulnerability can be manifest in a variety of cognitive and behavioral styles. I have proposed several issues to consider when reecting on narcissism. The lack of agreement on its denition fosters ongoing confusion and debate about the essential nature of narcissism, and certain labels and language may perpetuate negative bias. I described briey some prominent theories about healthy narcissism in an attempt to remind us that narcissistic phenomena are not strictly pathological and have roots in normal development. It is also important to consider that narcissistic phenomena likely exist on continua similar to other personality attributes, are fairly common, and may be on the rise in the United States. As well, several theories about the nature of pathological narcissism have been presented to encourage us to remember that the difcult patients who present with narcissistic problems were once children whose needs were not met by a larger familial and social structure. I would like now to turn to a summary of the ensuing articles in this issue.

This Issue
Following this introductory article, we begin with Levys discussion of various models of types and subtypes of pathological narcissism. It has been proposed that there are overt or grandiose types that correspond to the DSM-IV characterization of individuals who are attention seeking with obvious entitlement, arrogance, envy, and little apparent anxiety. This is in contrast to socalled covert or vulnerable narcissism, which manifests as excessive sensitivity to the reactions of others, social inhibition, and, apparently, modesty, but with underlying inated self-standards. Levy describes other variations in characterizing the expression of narcissism, but then explains that there is a growing consensus that individuals frequently exhibit both grandiose and vulnerable states that co-occur and oscillate. Kernbergs levels of narcissistic severity are also described and a case example is presented with specic technical recommendations for treating patients with narcissistic pathology. Roberts and Huprich follow with a discussion of the shortcomings of the present categorical diagnosis of NPD, which is limited to the grandiose manifestation of the pathology and is considered inadequate for capturing the complexity of the narcissism construct. They address the grandiose and vulnerable subtypes as well and propose that rather than being considered distinctive subtypes, they are better viewed as two dimensions that interact together to comprise narcissistic pathology. They recommend that assessing both dimensions, along with the existence of any healthy narcissistic attributes, offers the greatest clinical utility and most comprehensive understanding of patients individual patterns of narcissistic personality organization. Roberts and Huprich illustrate this complex interplay with the case of a patient who presented as shy

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and extremely sensitive, troubled by guilt, shame, and impaired self-esteem regulation, while at the same time harboring grandiose fantasies and a sense of superiority. Morey and Stagner examine nosologic controversies surrounding narcissism over the course of successive versions of the DSM, and emphasize the lack of empirical evidence supporting the existence of NPD as a distinct diagnostic entity. They recount the recent controversy around the proposal to eliminate NPD as a categorical diagnosis from DSM-5, and present evidence going a step beyond dimensional representations of narcissismthat narcissistic decits are shared by all personality disorders. More specically, Morey and Stagner demonstrate that a continuum using a core narcissistic factor of severity of impairment in mental representations of self and other (the Levels of Personality Functioning proposed for DSM-5) offers a more meaningful assessment of personality psychopathology. Their case presentation illustrates the contrast between the DSM-IV NPD and the proposed DSM-5 approach to narcissistic phenomena. Debilitating perfectionism is discussed by Dimaggio and Attina as one of the core pathological aspects of narcissism. Perfectionistic demands of self and others are used by patients with narcissistic difculties as an attempt to regulate self-esteem and action tendencies, but this typically results in ongoing criticism and disappointment for failure to attain the excessively high standards. This serves to fuel a perpetual cycle of inated expectations followed by deated defeat. Dimaggio and Attina also introduce metacognitive interpersonal therapy (MIT) as an approach they have applied to treating perfectionism and other narcissistic processes. They present the case of a patient treated using MIT to illustrate how to address some of the practical difculties in working with narcissistic tendencies, as well as showing specic techniques, such as promoting autobiographical thinking and increasing awareness of inner processes, to facilitate improvements in adaptive behavior and mental and emotional functioning. Rosegrant describes another compensatory pattern associated with people who have narcissistic difculties: sadomasochistic relationships. Individuals with pathological narcissism attempt to manage vulnerabilities such as decient self-esteem or fear of abandonment by masochistically submitting or sadistically exerting power over others, or often both. These tendencies are concomitant with concrete thinking and impairment in considering multiple or differing perspectives, limiting the therapists ability to effectively utilize various therapeutic interventions. Inevitably, the sadomasochism comes into play in the patienttherapist relationship and it is vitally important that therapists who treat patients with these types of difculties are aware of these patterns and how to best work with them. Rosegrant presents two cases illustrating the manifestation of sadomasochism in the treatment of narcissistic pathology and demonstrates how these patients can be provided therapeutically with the opportunity for experiencing and achieving new ways of relating. It is obvious that pathological narcissistic personality traits pose signicant challenges to building a therapeutic alliance. Ronningstam outlines a strategy that engages the patients as active participants in increasing their understanding of their own narcissistic processes. Using a collaborative approach, the therapist can assist the patient in learning about his or her patterns of self-regulation and grandiose compensation. Ronningstam presents an explanation of the complex nature and role of grandiosity, a trait that couples inferiority and superiority, selfcriticism and self-enhancement, fragility and assertiveness, and the uctuating nature of these processes that lie at the heart of pathological narcissism. Finally, Farber urges us to reect upon the ubiquitous use of the narcissism concept in not only todays parlance but also various contexts throughout much of written history. He challenges us to consider whether pathological narcissism is actually on the rise, or if every generation views its young people through this lens. Farber also makes it clear that narcissistic issues are not simply a disorder dened by the DSM, but exist, along with healthy narcissism, to a greater and lesser degree in all of us.

Case Illustration
Following is a clinical case description that I will use to illustrate some of the major ideas discussed by the contributing authors in this volume. Patient details and a summary of the course of treatment are presented rst, followed by outcome and prognosis. In the Clinical

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Practices and Summary section, I will apply to the case specic concepts and considerations that are discussed by the articles in this In Session issue.

Presenting problem and client description. At intake, Ms. M was 28 years old, married, and a doctoral student, highly intelligent, and verbal. Her presenting complaint was difculty with completing work effectively, particularly writing tasks, due to excessive anxiety and obsessions, in spite of the fact that she put in long hours everyday attempting to make progress. She was struggling to make headway on her dissertation, but often dwelled on fairly insignicant points for days on end. She reported that she often feels terrible about herself, has an ongoing fear of criticism, along with a need to get everything done perfectly. At the same time, she spoke with an air of arrogance about the prestige of her academic department and the renown of some of her professors. Ms. M was also concerned about and ashamed of her sexual preoccupations, which she vaguely described as having to do with sadomasochistic images. When not working, she spent many hours on the Internet looking at sadomasochistic pornography websites and would occasionally secretly visit S & M clubs in seedy parts of town. Her husband was vaguely aware of these aspects of her fantasy life, although she never requested his participation in any sadomasochistic sexual practices. Ms. M had a prominent lay position in her fundamentalist Christian church, and seemingly derived a great deal of satisfaction from that community and her contributions to its leadership. The couples active social life revolved around their church connections. At the same time, Ms. M said her intimate relationships often felt wooden. Not surprisingly, she and her husband were having marital problems and she characterized their interactions as constant power struggles. He often accused her of stubbornly refusing to consider his perspective. She agreed that she could be rigid about certain things, including her incessant devotion to work. Ms. M grew up in California, an only child in a working class family. Her mother was described as manipulative, demanding, and demeaning of Ms. M. She (Ms. M) was expected to support her mother emotionally and take care of most of the household duties, while maintaining a standard of excellence at school. Ms. M evidently was treated as a partner substitute for her mother, as her father was often out in bars with his friends. Her father was reportedly distant and critical, and Ms. M was sometimes beaten by him with a belt for perceived transgressions or for arbitrary reasons dictated by the mother. Case formulation. When Ms. M began treatment, an initial assessment interview indicated that she met DSM-IV criteria for generalized anxiety disorder on Axis I. Her perfectionism, immobilizing preoccupation with details, stubbornness and rigidity, and workaholism seemed to be consistent with DSM criteria for obsessive compulsive personality disorder. However, because I was trained to be familiar with signs of narcissistic disturbance, including problems with self-esteem regulation, compensating at times with grandiosity and perfectionism, and sadomasochistic relations, I recognized that there were narcissism issues at the heart of this case that DSM-IV could not capture, as Ms. M did not meet criteria for NPD. Course of treatment. We agreed to undertake a twice weekly psychodynamic psychotherapy. Building a working alliance was somewhat challenging, as I expected. In the beginning phase of treatment, Ms. M was controlling and provocative, talking constantly and tangentially, often losing the core point of her statements because of a need to present excessive details. She would also sometimes brag about her associations with famous professors in her department, speaking as if the therapist would be familiar with both their names and the content of their work (we are in different elds). Much of the time during this phase, my function was to listen and try to mirror back whatever the patient presented. Most of my statements were experienced as intrusive and so I inserted myself sparingly. It was difcult for her to allow me to be a separate person in the room, as a different perspective would be too threatening to her vulnerable sense of self. As time went on, and I demonstrated that I could be patient and take things at a pace that she needed, Ms. M began to trust me and opened up about how bad she felt about herself much

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of the time. When she entered her graduate program, she had imagined she would be a star and she suffered enormously about her impaired ability to be effective in spite of the excessive time and effort she devoted to her work. As treatment progressed, it became apparent that she was haunted by an endless list of shoulds, which she would constantly mentally review and remind herself how much she was failing to satisfy her obligations. She would set perfectionistic goals, fail to meet them, and then temporarily boost her morale by imagining meeting another unrealistic standard, fail to do so, and so the cycle went. A central theme illuminated by treatment was her tendency to be self-denigrating, loathing herself as an incompetent person deserving of punishment in some way. We came to understand that the expectation of punishment was reected in her fantasy life, which centered on a particular sort of sadomasochistic scenario: being tied up and beaten. She reported that often when she was anxious about a work assignment, she felt compelled to escape by looking at Internet pornography that included bondage scenes. Punishment themes were evident as well for most of her life in her work approach with others; that is, she would seemingly deliberately avoid meeting deadlines in classes and other work situations, anticipating that she would somehow be reprimanded (verbally whipped) by authority gures. This pattern was also apparent in therapy, at times, as the patient would be verbally provocative or do things like come late to sessions, attempting to goad me into retribution of some sort. I was eventually able to talk with Ms. M about this way of relating and she also began to tolerate my bringing our therapy relationship into consideration as well.

Outcome and prognosis. Much of the treatment focused on exploring the low self-esteem underlying Ms. Ms anxieties about her work and the sheer terror she sometimes experienced when having to write something. She made a great deal of progress in her ability to monitor her own psychological processes, allowing her to introduce a modicum of choice into her behaviors, rather than being compulsively driven to distract herself in a variety of ways. In addition, Ms. M has become better able to self-soothe and is quicker to identify and mitigate selfdenigrating attitudes that typically would paralyze her in her ability to work. Although still prone to procrastination, she is now able to more effectively structure herself so that the failures and disasters are fewer. Within the last 6 months of the 2-year treatment, Ms. M nally graduated and secured a very desirable job as a faculty member at a well-known college. She has become more politic in her interactions with others, challenging and provoking much less. She also reported improvement in her relationship with her husband, becoming more willing to devote more time to their relationship and experiencing a greater level of intimacy and enjoyment. Her connections to her church community feel somewhat richer, as Ms. M has become more capable of considering and appreciating others viewpoints. Ms. Ms sadomasochistic sexual preoccupation has persisted, but she feels less ashamed about it. While needing to terminate therapy to take her new job, Ms. M expressed that she could likely benet from additional treatment sometime in the future. Clinical Practices and Summary
The clinical example presented above serves to illustrate some of the issues taken up in detail by the authors of this issue:

The signicant limitations of using a categorical diagnosis to capture narcissistic difculties. It is clear in this case that the DSM-IV categorical personality disorder approach was insufcient in adequately characterizing the type of difculties most central for Ms. M. While she met criteria for obsessive-compulsive personality disorder (OCPD), this diagnosis did not at all address Ms. Ms fragile self-structure associated with narcissistic pathology. It is also commonly assumed that someone whose personality organization is described by OCPD is probably functioning at a higher neurotic level, which suggests that interpretative interventions would be effective and appropriate. However, had I asserted myself in interpreting the transference, defenses, or resistances in the early phase of treatment, I likely would have lost Ms. M as a patient, as her vulnerable narcissistic character may have felt shamed and overwhelmed.

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Utilizing a dimension based on self and interpersonal functioning is a richer and more effective way of capturing narcissistic phenomena. Clearly the OCPD categorical diagnosis did not do justice to the complex issues of Ms. M. DSM-5 has proposed that personality and personality disorders be assessed using functioning in the areas of self (identity and self-direction) and interpersonal (empathy and intimacy). If the Levels of Personality Functioning Scale were applied to Ms. M, then she would most closely resemble level 2, which is associated with attributes such as vulnerable self-esteem, emotional regulation dependent on external appraisal, unreasonably high personal standards, difculty reecting upon internal experience, compromised ability to consider alternative perspectives, and supercial connections in intimate relationships. This assessment may offer a more in-depth psychological portrait than the criteria of any one DSM-IV categorical personality disorder diagnosis. Challenges can be signicant in establishing a good working alliance with narcissistically impaired patients. Ms. M was initially a fairly difcult patient to work with. I needed to manage my reactions to not being tolerated as a separate person in the room, limited in what I could say, and sometimes feeling ineffective. I also needed to be aware of the provocations Ms. M presented me without being drawn into punishing her somehow. Knowing how narcissistically fragile Ms. M must be, I adopted an empathic listening stance and mirrored back her experiences when I could. I needed to look beyond the wall of words and grandiosity that threatened to shut me out. This approach paid off as Ms. M began to trust me enough to open up about her suffering and ways of thinking she found to be humiliating. The presence of sadomasochism related to narcissistic disturbance. While sexual perversions are not always present with narcissistic pathology, sadomasochistic relations are a frequent occurrence. Ms. M demonstrated how sadism and masochism are both present in individuals, even though it often looks like one stance is dominant. Ms. Ms masochistic tendencies included fantasizing about being tied and beaten, trying to provoke her husband, her professors, and me into chastising her, and constantly beating up on herself internally with self-criticism. On the other hand, she was subtly sadistic when she mistreated her husband by insisting on working all the time, scoffed at me if I did not know the work of her famous faculty, or could not consider any alternative viewpoints. Narcissism manifests in both grandiose and vulnerable ways. Clearly for Ms. M, grandiosity was often used as a defense against feeling the despair associated with her sense of herself as a failure deserving punishment. She needed to see herself with a shining future as part of an elite academic department to try to protect herself from the reality that she was struggling a great deal with her academic work. It was apparent that her self-states could oscillate between grandiose ination and vulnerable collapse. The destructive presence of perfectionism. Related to the grandiose compensatory strategy, Ms. M was prone to employing perfectionistic standards for herself. For example, rather than simply setting herself the task of nishing a project she had been struggling with for months, she would fantasize about having her work chosen for special honors as a way of trying to buoy her self-esteem in the face of her difculties with productivity. When she realized she might barely manage to nish, her self-image would come crashing down once again. Even when she did accomplish something successfully, her satisfaction was short-lived and she would set another lofty goal. Similarly, there were times when she would launch into a litany about how awed her husband, friends, and associates were and then be miserable about feeling disconnected from people. The importance of healthy narcissistic urges as central to adaptive functioning. In spite or her struggles with self-esteem and her forays into grandiose overcompensation, Ms. M did possess positive ambitions for herself as an aspiring academic and as a leader in her church. When not plagued with self-doubt, she was able to take genuine and appropriate pride in her contributions and her efforts at being a good member of the community. She also longed to create a better life for herself than that of her parents. This motivated her to invest in therapyin spite of how difcult she found it at timesto improve her psychological and emotional life to be a better wife, friend, colleague, and, hopefully someday, a good, empathic mother.

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Selected References and Recommended Readings

American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, DC: American Psychiatric Association. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association. Auerbach, J. S. (1990). Narcissism: Reections on others images of an elusive concept. Psychoanalytic Psychology, 7, 545564. Bach, S. (1985). Narcissistic states and the therapeutic process. Northvale, NJ: Jason Aronson Inc. Bender, D. S., Morey, L. C., & Skodol, A. E. (2011). Toward a model for assessing level of personality functioning in DSM-5, Part I: A review of theory and methods. Journal of Personality Assessment, 93, 332346. Dhawan, N., Kunik, M. E., Oldham, J., & Coverdale, J. (2010). Prevalence and treatment of narcissistic personality disorder in the community: A systematic review. Comprehensive Psychiatry, 51, 333339. Foster, J. D., & Campbell, W. K. (2007). Are there such things as Narcissists in social psychology? A taxometric analysis of the Narcissistic Personality Inventory. Personality and Individual Differences, 43(6), 13211332. Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press. Kohut, H. (1977). The restoration of the self. New York, NY: International Universities Press. Kohut, H. (1984). How does analysis cure? Chicago, IL: University of Chicago Press. Lasch, C. (1979). The culture of narcissism: American life in an age of diminishing expectations. New York, NY: W. W. Norton & Co. PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations. Pincus, A. L., Ansell, E. B., Pimentel, C. A., Cain, N. M., Wright, A. G. C., & Levy, K. N. (2009). Initial construction and validation of the Pathological Narcissism Inventory. Psychological Assessment, 21, 365379. Stinson F. S., Dawson D. A., Goldstein R. B., Chou S. P., Huang B., Smith S. M. . . . , Grant B. F. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69(7), 10331045. Widiger, T. A., Simonsen, E., Krueger, T. Livesley, J., & Verheul, R. (2005). Personality research agenda for DSM-V. Journal of Personality Disorders, 19(3), 315338. Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of DSM- IV personality disorders in psychiatric outpatients. American Journal of Psychiatry, 162, 19111918.

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