The Narcissistic and Borderline Disorders

An Integrated Developmental Approach

James F. Masterson, M.D.

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780876302927
• eBook ISBN:
  9781134842735
• Topic: Medicine
• Subtopic: Mental Health in Psychology

This volume presents a fully integrated developmental approach that not only differentiates between varying etiologies of the narcissistic and borderline disorders but also provides a detailed guide to effective treatment.

I. The Psychopathology of Narcissism

The term “narcissism” has recently become so linked with one form of psychopathology that it is often overlooked that a normally developed or healthy narcissism, one definition of which is the libidinal investment of the self, is vital to a healthy adaptation. As originally described by Freud (25), the global infantile narcissism gradually differentiates with growth and maturation to invest the individual self-representation and provide the libidinal investment for the development of the capacities for regulating self-esteem, for self-assertion, for pursuit of one’s own unique interests, for one’s standards, ideals and ambitions.

This section presents the narcissistic personality disorder as one part of the wider spectrum of the psychopathology of narcissism: narcissistic defenses against an underlying borderline personality disorder and the narcissistic psychopathology of the borderline.

My interest in the narcissistic personality disorder has stemmed from and followed my work on the borderline syndrome (83, 86). From a superficial clinical point of view, these two disorders can be seen as opposite sides of the coin, with the borderline syndrome showing a deficient libidinal investment of the self, and the narcissistic personality disorder, on the surface at least, showing a grandiose and pathologically excessive libidinal investment of the self. This section makes clear how the psychopathology of narcissism differs in the two disorders. Kohut’s failure to make this distinction has dramatized and greatly exaggerated the prevalence of the narcissistic personality disorder as a clinical problem. In my own clinical experience and that of many of my colleagues, as well as in the experience of hundreds of therapists across the country whom I have questioned, borderline patients far outnumber those with a narcissistic personality disorder in clinical practice.

Chapter 1 describes the clinical picture of the narcissistic personality disorder and then turns to developmental theory to account for that clinical picture. It thereby integrates the theoretical understanding of the narcissistic personality disorder with that of the borderline presented in prior publications and updated and elaborated in Chapters 7 to 12. These theoretical views are then contrasted with those of Kernberg (43-50) and Kohut (58-63). Chapter 2 on Differential Diagnosis furthers this integrated approach by emphasizing the same developmental theory to differentiate between the narcissistic personality disorder and the borderline personality disorder. It then devotes a special section to the presentation of a case illustrating a narcissistic defense against a borderline personality disorder; finally, it differentiates the two (narcissistic and borderline personality disorders) from other diagnostic categories such as psychosis, neurosis affective disorder, etc. Chapter 3 presents the case history of a narcissistic personality disorder and demonstrates how the clinical evidence is used to determine the intrapsychic structure. Chapters 4 and 5, presenting the psychoanalytic psychotherapy of this patient, demonstrate the vicissitudes of the intrapsychic structure of the narcissistic personality disorder as they ebb and flow in response to the therapist’s interventions. Chapter 6 describes the narcissistic psychopathology found in the borderline, gives an explanatory developmental theory, contrasts this view with that of Winnicott (117) on the false self and then presents two detailed illustrations of treatment of borderline patients with a false self.

1

The Narcissistic Personality Disorder

THE CLINICAL PICTURE

The main clinical characteristics of the narcissistic personality disorder are grandiosity, extreme self-involvement and lack of interest in and empathy for others, in spite of the pursuit of others to obtain admiration and approval. The patient manifesting a narcissistic personality disorder seems to be endlessly motivated to seek perfection in all he or she does, to pursue wealth, power and beauty and to find others who will mirror and admire his/her grandiosity. Underneath this defensive façade is a feeling state of emptiness and rage with a predominance of intense envy.

Three levels of functioning can be distinguished in the narcissistic disorders:

(a) Effective surface adaptation with success due to talent or skill. Such patients come for psychotherapy because of neurotic symptoms, sexual difficulty or difficulty in object relations.

(b) Patients with severe difficulty in object relations, usually along with neurotic symptoms and/or sexual problems.

(c) Those who function on a borderline level with ego weakness.

Meissner (90) describes four clinical types of narcissistic disorders:

1) phallic-narcissistic;

2) Nobel-prize narcissistic;

3) manipulatory or psychopathic;

4) needy, clinging and demanding.

To this list must be added what I call the “closet narcissist.” Although, in a theoretical sense, all narcissists are closet narcissists, I am referring to the patient who presents him/herself as timid, shy, inhibited and ineffective—only to reveal later in therapy the most elaborate fantasies of the grandiose self.

The cases described below illustrate the clinical picture of the narcissistic disorder:

CASE ILLUSTRATIONS

Mr. X

Mr. X, 48, was married with two sons.

History of Present Illness

The patient came for treatment with the report that he had been one of the few men in line to be chosen as chief executive of a large corporation. Eagerly looking forward to this appointment, he was astounded and disappointed when called in by the board of directors and told that the appointment would go to his rival. He was even more astounded to learn the reason. The quality of his work was excellent, but his relationship with his employees and co-workers was so poor, that it made him ill-equipped to run the company.

Depressed and distraught, he returned home to seek support from his wife. To the contrary, she reinforced the observation of the board, saying he had the same problems with her and with their two children, with whom they had had considerable conflict; she added that he was for the most part quite self-involved and, although he could be quite stimulating and charming when he chose to be, usually he pursued his own interests and seemed quite unaware of either his wife’s or his children’s needs.

In the initial interview, as he came close to pointing out to me, the therapist, that obviously all of these people were mistaken, he checked himself and then reflected that there really must be something wrong with his perception, although he really couldn’t see what it was. He had many complaints about his wife, her emotional inconsistency, coldness, needs and clinging. In the course of their 20 years of marriage, he had had a number of superficial affairs which rarely went beyond sexual liaisons.

He reported that both at work and with his family he felt he knew better how to manage situations and was quite devaluing and intolerant of their opinions. He smoked and drank heavily.

He complained further that he was not getting enough feedback from his wife, that “he was a sucker for women whom he admired and respected, who flattered him, and he expected such flattery and responded very positively to it. However, in his various affairs, after the early phase of sexual attraction and romance had run its course, he tended to lose interest and end one affair only to start another shortly afterwards.

He strove for perfection in his work and was intolerant of subordinates’ failures to meet his standards, because it would reflect poorly on his own image. He was intolerant of any criticism and tended to lash out with anger without adequate thought or restraint. He had many outside interests: music, art, golf. The only neurotic symptom he reported was tension headaches; however, he reported an obsessive fear of and preoccupation with loneliness and death.

Past History

The patient was born in the West, the third of three children in a family which was serious, extremely religious and restrictive. He described being close to his father whom he liked, although the father was away from home a great deal when he was a child. The mother, he said, was much more punitive and restrictive than his father and administered all the discipline. There was very little pleasure in the home, since fun was not permitted, but emphasis was laid upon honor and duty. He was an outstanding student and athlete in high school and college, without any symptomatic episodes.

Evaluation

In the early sessions he demonstrated the following: Very early he began to have the same complaint about object relations with me that he had with his wife—“that there was not enough feedback”—when I did not ask a lot of questions. It was clear that on the one hand he idealized me and wished to call me by my first name, while on the other hand he tended to compete with me and devalue my various observations about him. This patient probably represents what has been described as the phallic, narcissistic character or as the most functional of the narcissistic disorders.

Mr. Y

The second patient is an example of the more common type of narcissistic disorder who comes for treatment with a middle level of functioning. The patient is a 36-year-old married man with two children, whose chief complaint is that he is in such a deep hole that he doesn’t know how to get out of it other than by coming for treatment.

He was also stunned to hear from his wife that she was planning to divorce him and that she had felt it necessary to resort to a number of brief affairs over their 12-year marriage because of his self-centeredness and lack of involvement with her. He stated clearly that he was unable to be close to anyone, that he tended to pursue his own interests in a selfish manner, ignoring the needs of others, including his wife and children, until they confronted him with his egocentricity. Only then, in such a crisis atmosphere, would he become upset, change his behavior and attempt to conform to their wishes. He reported that they had had several of these crises in his marriage (although he hadn’t known about his wife’s affairs), and each time the crisis subsided he went back to his old habits. He said: “It seems that I have a need to be loved but cannot love; I am selfish; there is something horrible inside of me.” He was deeply depressed, with vegetative signs. He was successful in his work as a businessman but had a number of sexual problems manifested by sexual acting-out. His memory of his childhood was sketchy, as he could recall very few of the events of those early developmental years.

Evaluation

This patient probably represents the middle range of narcissistic pathology, with extreme difficulty with object relations, neurotic symptomatology and sexual conflicts, although he is able to function quite well at work.

A DEVELOPMENTAL THEORY

Developmental theory sheds light on the developmental arrest and intrapsychic structure of the narcissistic personality disorder.

Level of Developmental Arrest of the Narcissistic Personality Disorder

It is a tenet of object relations theory (15, 16, 37, 38, 40, 41, 54, 55, 56, 57) that ego defense mechanisms and ego functions mature in parallel with the maturation of self-and object representations. A controversy has arisen over how to explain that the narcissistic personality disorder seems to violate this tenet in that a very primitive self-object representation is seen alongside a seemingly high capacity for ego functioning.

To put it in developmental terms, although the self-object representation is fused, the narcissistic personality disorder seems to get the benefit for ego development that is believed to come about only as a result of separation from that fusion. There has yet been no satisfactory resolution of this dilemma, either by myself (see below) or other authors (44, 63). We hope in the future to develop a theoretical postulate to resolve this ambiguity.

One of the functions of the rapprochement crisis during the separation-individuation phase of development is to bring into accord with reality by phase-appropriate disappointment and frustration those archaic structures, the grandiose self and the omnipotent object (76). Let us briefly review Mahler’s observations on this isssue: Mahler noted that the chief characteristic of the practicing period is the child’s great narcissistic investment in his or her own functions and his/her own body, as well as in the objects and objectives of his/her expanding “reality.” He/she seems relatively impervious to knocks, falls and other frustrations.

The rapprochement subphase (15-22 months approximately) begins with the mastery of upright locomotion. Alongside the growth of the child’s cognitive faculties and the increasing differentiation of his/her emotional life, there is also, however, a waning of his/her previous imperviousness to frustration, as well as of his/her relative obliviousness to the mother’s presence.

An increased separation anxiety is observed: At the height of mastery, toward the end of the practicing period, there is increasingly clear differentiation between the self-representation and the object-representation. The toddler starts to lose his prior sense of grandiosity and omnipotence, and it begins to dawn on him that the world is not his oyster and that he must cope with it on his own.

The toddler returns to woo the mother, demanding that she share every aspect of his/her life, but it no longer works. The self-representation and the object representation are well on the way to differentiation. In this manner the infantile fantasies of grandiosity and omnipotence are brought into accord with reality.

The fixation of the narcissistic personality disorder must occur before this event because clinically the patient behaves as if the object representation were an integral part of the self-representation—an omnipotent, dual unity. The possibility of the existence of a rapprochement crisis doesn’t seem to dawn on this patient. The fantasy persists that the world is his oyster and revolves about him. In order to protect this illusion, he must seal off by avoidance, denial and devaluation those perceptions of reality that do not fit or resonate with this narcissistic, grandiose self-projection. Consequently, he is compelled to suffer the cost to adaptation that is always involved when large segments of reality must be denied.

Why the fixation occurs at this level is a complex and poorly understood matter. Presumably, as with the borderline, the etiologic input can come from both sides of the nature-nurture spectrum. However, the input from both sides is much clearer in the borderline than in the narcissistic personality disorder.

Some of the mothers in narcissistic personality disorders are basically emotionally cold and exploitive. They ignore their children’s separation-individuation needs in order to mold them into objects that will justify their own perfectionistic, emotional needs. The child’s real individuation needs suffer as he or she resonates with the mother’s idealizing projections. This identification with the mother’s idealization leads to preservation of the grandiose self, which defends against the perception of the mother’s failures and the child’s associated depression.

A second possibility is suggested by the fact that in normal development the child, particularly the male, turns strongly in the early practicing phase, before rapprochement has occurred, to identify with the father. The child, experiencing an abandonment depression at the hands of the mother, could use this normal pathway as a vehicle or channel to “rescue” him/her from the abandonment depression and the mother. Rather than undergo the normal developmental process of identification with the father as a second, new, non-symbiotic object, the child transfers wholesale the symbiotic relationship with the mother onto the father in order to deal with his abandonment depression. The father thus becomes a target for projection of the symbiotic relationship with the mother. If the father is a narcissistic personality and this transfer occurs before the rapprochement phase, the child’s grandiose self will still be preserved and reinforced through identification with the narcissistic father—thus producing a narcissistic disorder.

If the transfer occurs after the rapprochement phase has brought infantile grandiosity and omnipotence into accord with reality, the identification with the narcissistic disorder of the father will occur after the formation of the split object relations unit of the borderline, and a narcissistic defense against a borderline disorder will be superimposed on the underlying borderline intrapsychic structure (see pages 32-37). In other words, once the grandiose self has been brought into accord with reality during the rapprochement phase, it disappears and gives way to the separate split self-and object representations. Any turn to a narcissistic father after this event has taken place can only result in superimposing a later narcissistic identification on top of an underlying borderline intrapsychic structure.

This possibility raises some intriguing but so far unresolved developmental questions. It suggests that a narcissistic father may be essential for the production of a narcissistic defense against a borderline ...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• Introduction
• I The Psychopathology of Narcissism
• II The Borderline Personality Disorder
• III Reflections
• Bibliography
• Index