Narcissistic Personality Disorder

Narcissistic Personality Disorder

Willa Cather's title "Paul's Case" (1905) invites us to ponder the question, "What exactly is Paul's Case?" Cather immediately informs us that Paul's case is mysterious. His own father is "perplexed" about his son's behavior, and the school faculty, who meet with Paul to discuss his recent suspension, speak of Paul with such "rancor" and "aggrieved ness" that it is obvious that Paul's is "not a usual case" (Cather, 1991, p. 221). At first, it appears that Paul is, perhaps, simply filled with the arrogance that adolescence sometimes brings, but, as Cather continues with Paul's case history, we learn that his problem is more deeply rooted. Paul's problem drives him to take his own life, and simple adolescent arrogance does not lead to such drastic measures. My diagnosis is that Paul suffers from what contemporary psychiatry calls a "narcissistic personality disorder."

The term, "narcissism" comes, of course, from the Greek myth of Narcissus. Freud, who drew upon mythology to assist in his conceptual formulations of psychopathology, formally introduced the term narcissism into the psychiatric literature in his 1914 paper On Narcissism. Freud, (1914) states that, "narcissism is a borderline concept that should be used as key to everything" (p. 85). The term received recognition within the early psychoanalytic intelligentsia and has been historically rooted in the psychoanalytic tradition. Since Freud first introduced the term, it has been used to help explain disorders ranging from the mildly neurotic to the psychotic. According to Freud's theory the origins of this disorder would have derived from internal factors. He believed that humans are "bad" and it does not have to do with the environment. He would have most likely agreed that it may start of in the unconscious and then somehow moves to the conscious when a child becomes fixed in a particular stage of his or her life. Presently, the American Psychiatric Association uses the term to define a personality and outlines the diagnostic criteria for the narcissistic personality disorder in the Diagnostic and Statistical Manual of Mental Disorders.4th edition, Text Revised (DSM-IV).

To receive the diagnosis of a narcissistic personality disorder, a person must meet five of nine criteria: Paul case appears to be a prototypical meeting all nine criteria. Amazingly, it seems that Willa Cather by instinct set forth the diagnostic criteria for a narcissistic personality disorder about ninety years before scientists reached a firm, empirically validated consensus.

Though not as physically striking--nor as outwardly arrogant--as Narcissus, Paul attracts attention and begs for analysis. A number of critics have set forth interesting analyses of Paul's inner world. Michael N. Salda presents an argument that on the night that Paul arrives home late and retreats to the basement to avoid his father, he never actually leaves the basement; the scenes that follow, according to Salda, occur only in Paul's imagination (Salda, 1992). Paying somewhat less attention to Paul's grandiose fantasy life, Edward Pitcher presents Paul as the embodiment of a "Faustian temperament" in conflict with the "capitalist machine" (Pitcher, 1991, p. 550). More closely aligned with the forthcoming analysis of Paul is Philip Page's description of Paul in terms of a "metaphor of theatricality" (Page, 1991, 553). Page's idea of Paul as an actor living out an inflated drama in his imagination is quite consistent with the narcissistic personality. Although each of these critics offers us a glimpse into Paul's inner world, I think that through the lens of the DSM-IV, we can gather a more comprehensive picture of Paul's case and a better understanding of why both he and Narcissus experience such a tragic fate.

The DSM-IV states that the essential features of a Narcissistic Personality Disorder are a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present a variety of contexts, as indicated by five (or more) of the following:

I. Has a grandiose sense of self-importance (e.g., exaggerates).

II. Achievements and talents, expects to be recognized as superior without commensurate achievements).

III. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

IV. Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).

V. Requires excessive admiration, has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.

VI. Is interpersonally exploitative, i.e., takes advantage of others to achieves his or her own ends.

VII. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.

VIII. Is often envious of others or believes that others are envious of him or her.

IX. Shows arrogant, haughty behavior or attitudes (APA, 1994, 661).

Beyond these skeleton criteria, the DSM-IV fleshes out the narcissistic personality disorder through commenting on these diagnostic features and noting common associated features, some of which are relevant to Paul's case. This commentary along with a presentation of some respected theorists in the area of narcissism will assist in understanding the dynamics of Paul's personality. The underlying web that holds the narcissistic personality together is a fragile self-esteem that craves constant attention, either real or imagined. Without this constant attention, which is often achieved through a grandiose fantasy life, the narcissist's fragile self-esteem suffers. If the narcissist is criticized in a way that threatens the grandiose sense of self, he or she may experience feelings of "shame or humiliation," which can lead to "social withdrawal, depressed mood" or "major depressive disorder" (APA, 1994, p. 660). Karen Horney, MD, an eminent theorist in the history of psychiatry, explains that in the case of "repeated failures in enterprises or in human relations," the narcissist's underlying "self-hate" may lead to psychotic episodes and suicide (Horney, 1950, p. 195). The narcissist's maintenance of his or her vulnerable