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The hallmark of narcissistic personality disorder is grandiosity. The narcissist harbors a strong sense of entitlement, self-aggrandizing fantasies, and a craving for admiration. In severe cases, she may be envious, lacking in empathy, and ready to exploit others in the pursuit of her lofty ambitions. Although she can be charismatic and charming, she more often seems self-absorbed, controlling, and insensitive. If she feels slighted or ridiculed, she might be provoked into a fit of destructive rage and revenge seeking. Such a paroxysmal reaction is sometimes called ‘narcissistic rage’ and can have disastrous consequences for all those involved, including the narcissist herself.

In the novel The Picture of Dorian Gray, both the characters of Lord Henry Wooton and Dorian Gray are strongly narcissistic. Lord Henry’s narcissism is insightful and often quite charming and no doubt similar to that of his creator and alter ego, Oscar Wilde.

I make a great difference between people. I choose my friends for their good looks, my acquaintances for their good characters, and my enemies for their good intellects. A man cannot be too careful in the choice of his enemies. I have not got one who is a fool. They are all men of some intellectual power, and consequently they all appreciate me.

On the other hand, Dorian Gray’s narcissism is cold and destructive, leading, among other things, to the suicide of actress Sibyl Vane. In Chapter 7, Sibyl tells Dorian that he brought her to “something [higher] of which all art is but a reflection” and made her understand the nature of true love. Instead of feeling flattered or humbled or otherwise moved, Dorian castigates Sibyl for her poor acting, claiming that it has killed off any love that he might ever have had for her.

‘Yes,’ he cried, ‘you have killed my love. You used to stir my imagination. Now you don’t even stir my curiosity. You simply produce no effect. I loved you because you were marvellous, because you had genius and intellect, because you realized the dreams of great poets and gave shape and substance to the shadows of art. You have thrown it all away. You are shallow and stupid. My God! How mad I was to love you! What a fool I have been! You are nothing to me now. I will never see you again. I will never think of you. I will never mention your name. You don’t know what you were to me, once. Why, once… Oh, I can’t bear to think of it! I wish I had never laid eyes upon you! You have spoiled the romance of my life…’

A study carried out by Board and Fritzon at the University of Surrey in England found that narcissistic personality disorder, histrionic personality disorder, and another personality disorder called anankastic personality disorder are actually more common in high-level executives than in mentally disordered criminal offenders at the high-security Broadmoor Hospital.

This suggests that people commonly benefit from strongly ingrained and potentially maladaptive personality traits. For example, people with narcissistic personality disorder may be highly ambitious, confident, driven, and able to exploit people and situations to maximum advantage. People with histrionic personality disorder may be adept at charming and manipulating others, and thus adept at building and exercising business relationships.

In their study, Board and Fritzon described the executives with a personality disorder as ‘successful psychopaths’ and the criminal offenders as ‘unsuccessful psychopaths,’ and it may be that highly successful people and disturbed psychopaths have more in common than first meets the eye. As the psychologist and philosopher William James put it more than a hundred years ago, ‘When a superior intellect and a psychopathic temperament coalesce… in the same individual, we have the best possible condition for the kind of effective genius that gets into the biographical dictionaries.’

Over in the United States, Mullins-Sweatt and her colleagues investigated how successful psychopaths might differ from unsuccessful ones. They asked several members of the psychology and law division of the American Psychological Association, professors of clinical psychology, and criminal attorneys to first identify and then to rate and describe one of their acquaintances (if any) who could be counted as successful and also conformed to psychologist Robert Hare’s definition of a psychopath:

…social predators who charm, manipulate and ruthlessly plow their way through life… Completely lacking in conscience and feeling for others, they selfishly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret.

From the responses that they collated, the researchers found that successful psychopaths matched unsuccessful ones in all respects but one: conscientiousness. So, it seems that the key difference between unsuccessful and successful psychopaths is that the former behave impulsively and irresponsibly, whereas the latter are able to inhibit or at least restrain destructive tendencies and build on their achievements.

Narcissistic personality disorder is, of course, named for the Greek myth of Narcissus, of which there are several versions. In Ovid’s version, which is the most commonly related, the nymph Echo falls in love with Narcissus, a youth of extraordinary beauty. As a child, Narcissus was prophesized by Teiresias, the blind prophet of Thebes, to ‘live to a ripe old age, as long as he never knows himself’.

One day, Echo followed Narcissus through the woods as he hunted for stags. She longed to speak to him but dared not utter the first word. Overhearing her footsteps, the youth cried out, “Who’s there?” to which she responded, “Who’s there?” When at last she revealed herself, she rushed to embrace Narcissus, but he scorned her and pushed her away—just, in fact, as Dorian did Sibyl. Echo spent the rest of her life pining for Narcissus and slowly withered away until there was nothing left of her but her voice.

Some time after his encounter with Echo, Narcissus went to quench his thirst at a pool of water. Seeing his own image in the water, he fell in love with it. But each time he bent down to kiss it, it seemed to disappear. Narcissus grew ever more thirsty, but would not leave or disturb the pool of water for fear of losing sight of his reflection. In the end, he died of thirst, and there, on that very spot, appeared the narcissus flower, with its bright face and bowed neck.

What does this myth mean? On one level, it is an admonition to treat others as we would ourselves be treated, and in particular to be considerate in responding to the affections of others, which, as with Echo, are often so raw and visceral as to be existential. After being rejected by him, poor Echo had no self and no being outside of Narcissus, and ‘slowly withered away until there was nothing left of her but her voice’.

On another level, the myth is a warning against vanity and self-love. Sometimes we get so caught up in ourselves, in our own little egos, that we lose sight of the bigger picture and, as a result, pass over the beauty and bounty that is life. Paradoxically, by being too wrapped up in ourselves, we actually restrict our range of perception and action and, ultimately, our potential as human beings. And so, in some sense, we kill ourselves, like so many ambitious or self-centered people. Treating other people badly is a sure sign that we are still trapped in ourselves.

Teiresias prophesized that Narcissus would ‘live to a ripe old age, as long as he never knows himself’, because to truly know oneself is also to know that there is nothing to know. Our self, our ego, is nothing but an illusion, nothing more substantial than the ever-receding reflection that Narcissus was unable to grasp. Ultimately, Narcissus’s ego’s boundaries dissolved in death and he merged back into the world in the form of a flower. In Greek myth, the hero—Theseus, Hercules, Odysseus—has to die and travel through the underworld (the unconscious) before re-emerging as a hero. He has to conquer himself, to die to himself, to become more than merely human.

Echo had not enough ego, and Narcissus far too much. The key is to find the right and dynamic equilibrium, to be secure in oneself and yet to be able to dissociate from the envelope that we happen to have been born into.

References

  • Board BJ and Fritzon KF (2005): Disordered personalities at work. Psychology, Crime and Law 11:17-23.
  • James W (1902): The Varieties of Religious Experience, Lecture 1 ‘Religion and Neurology’, Footnote 6.
  • Mullins-Sweat S et al. (2010): The Search for the Successful Psychopath. Journal of Research in Personality 44:554-558.

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Is the medicalization of human suffering doing more harm than good?

‘Mental disorder’ is difficult to define.

Generally speaking, mental disorders are conditions that involve either loss of contact with reality or distress and impairment. These experiences lie on a continuum of normal human experience, and so it is impossible to define the precise point at which they become pathological.

What’s more, concepts such as borderline personality disorder, schizophrenia, and depression listed in classifications of mental disorders may not map onto any real or distinct disease entities. Even if they do, the symptoms and clinical manifestations that define them are open to subjective judgement and interpretation.

In an attempt to address these problems, classifications of mental disorders such as DSM-5 and ICD-10 adopt a ‘menu of symptoms’ approach, and rigidly define each symptom in technical terms that are often far removed from a person’s felt experience. This encourages mental health professionals to focus too narrowly on validating and treating an abstract diagnosis, and not enough on the person’s distress, its context, and its significance or meaning.

Despite using complex aetiological models, mental health professionals tend to overlook that a person’s felt experience often has a meaning in and of itself, even if it is broad, complex, or hard to fathom. By being helped to discover this meaning, the person may be able to identify and address the source of his distress, and so to make a faster, more complete, and more durable recovery. Beyond even this, he may gain important insights into himself, and a more refined and nuanced perspective over his life and life in general. These are rare and precious opportunities, and not to be squandered.

A more fundamental problem with labelling human distress and deviance as mental disorder is that it reduces a complex, important, and distinct part of human life to nothing more than a biological illness or defect, not to be processed or understood, or in some cases even embraced, but to be ‘treated’ and ‘cured’ by any means possible—often with drugs that may be doing much more harm than good. This biological reductiveness, along with the stigma that it attracts, shapes the person’s interpretation and experience of his distress or deviance, and, ultimately, his relation to himself, to others, and to the world.

Moreover, to call out every difference and deviance as mental disorder is also to circumscribe normality and define sanity, not as tranquillity or possibility, which are the products of the wisdom that is being denied, but as conformity, placidity, and a kind of mediocrity.

The evolution of the status of homosexuality in the classifications of mental disorders highlights that concepts of mental disorder can be little more than social constructs that change as society changes. PTSD, anorexia nervosa, bulimia nervosa, depression, and deliberate self-harm (non-suicidal self-injury) can all be understood as cultural syndromes. Yet, for being in the DSM and ICD, they are usually seen, and largely legitimized, as biological and therefore universal expressions of human distress.

Other pressing problems with the prevalent medical model is that it encourages false epidemics, most glaringly in depression, bipolar disorder, and ADHD. Data from the US National Health Interview Survey indicate that, in 2012, 13.5% (about 1 in 7) of boys aged 3-17 had been diagnosed with ADHD, up from 8.3% in 1997. It also encourages the wholesale exportation of Western mental disorders and Western accounts of mental disorder. Taken together, this is leading to a pandemic of Western disease categories and treatments, while undermining the variety and richness of the human experience.

For example, in her recent book, Depression in Japan, anthropologist Junko Kitanaka writes that, until relatively recently, depression (utsubyō) had remained largely unknown to the lay population of Japan. Between 1999 and 2008, the number of people diagnosed with depression more than doubled as psychiatrists and pharmaceutical companies urged people to re-interpret their distress in terms of depression. Depression, says Kitanaka, is now one of the most frequently cited reasons for taking sick leave, and has been ‘transformed from a rare disease to one of the most talked about illnesses in recent Japanese history’.

Many critics question the scientific evidence underpinning such a robust biological paradigm and call for a radical rethink of mental disorders, not as detached disease processes that can be cut up into diagnostic labels, but as subjective and meaningful experiences grounded in personal and larger sociocultural narratives.

Unlike ‘mere’ medical or physical disorders, mental disorders are not just problems. If successfully navigated, they can also present opportunities. Simply acknowledging this can empower people to heal themselves and, much more than that, to grow from their experiences.

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Generally speaking, culture-specific, or culture-bound, syndromes are mental disturbances that only find expression in certain cultures or ethnic groups, and that are not comfortably accommodated by Western psychiatric classifications such as the DSM and ICD. DSM-IV defined them as ‘recurrent, locality-specific patterns of aberrant behavior and troubling experience…’

One example of a culture-bound syndrome is dhat, which is seen in men from South Asia, and involves sudden anxiety about loss of semen in the urine, whitish discoloration of the urine, and sexual dysfunction, combined with feelings of weakness and exhaustion. The syndrome may originate in the Hindu belief that it takes forty drops of blood to create a drop of bone marrow, and forty drops of bone marrow to create a drop of semen, and thus that semen is a concentrated essence of life.

DSM-5, published in 2013, replaces the notion of culture-bound syndromes with three ‘cultural concepts of distress’: cultural syndromes, cultural idioms of distress, and cultural explanations for distress. Rather than merely listing specific cultural syndromes, DSM-5 adopts a broader approach to cultural issues, and acknowledges that all mental disorders, including DSM disorders, can be culturally shaped.

However, some DSM disorders are, it seems, much more culturally shaped than others. For instance, PTSD, anorexia nervosa, bulimia nervosa, depression, and deliberate self-harm (non-suicidal self-injury) can all be understood as cultural syndromes. Yet, for being in the DSM, they are usually seen, and largely legitimized, as biological and therefore universal expressions of human distress.

Thus, one criticism of classifications of mental disorders such as DSM and ICD is that, arm in arm with pharmaceutical companies, they encourage the wholesale exportation of Western mental disorders, and, more than that, the wholesale exportation of Western accounts of mental disorder, Western approaches to mental disorder, and, ultimately, Western values such as biologism, individualism, and the medicalization of distress and deviance.

In her recent book, Depression in Japan, anthropologist Junko Kitanaka writes that, until relatively recently, depression (utsubyō) had remained largely unknown to the lay population of Japan. Between 1999 and 2008, the number of people diagnosed with depression more than doubled as psychiatrists and pharmaceutical companies urged people to re-interpret their distress in terms of depression. Depression, says Kitanaka, is now one of the most frequently cited reasons for taking sick leave, and has been ‘transformed from a rare disease to one of the most talked about illnesses in recent Japanese history’.

In Crazy Like Us: The Globalization of the American Psyche, journalist Ethan Watters shows how psychiatric imperialism is leading to a pandemic of Western disease categories and treatments. Watters argues that changing a culture’s ideas about mental disorder actually changes that culture’s disorders, and depletes the store of local beliefs and customs which, in many cases, provided better answers to people’s problems than antidepressants and anti-psychotics. For Watters, the most devastating consequence of our impact on other cultures is not our golden arches, but the bulldozing of the human psyche itself.

He writes:

Looking at ourselves through the eyes of those living in places where human tragedy is still embedded in complex religious and cultural narratives, we get a glimpse of our modern selves as a deeply insecure and fearful people. We are investing our great wealth in researching and treating this disorder because we have rather suddenly lost other belief systems that once gave meaning and context to our suffering.

Distressed people are subconsciously driven to externalize their suffering, partly to make it more manageable, and partly so that it can be recognized and legitimized. According to medical historian Edward Shorter, our culture’s beliefs and narratives about illness provide us with a limited number of templates or models of illness by which to externalize our distress. If authorities such as psychiatrists and celebrities appear to endorse or condone a new template such as ADHD or deliberate self-harm, the template enters into our culture’s ‘symptom pool’ and the condition starts to spread. At the same time, tired templates seep out of the symptom pool, which may explain why conditions such as ‘hysteria’ and catatonic schizophrenia (schizophrenia dominated by extreme agitation or immobility and odd mannerisms and posturing) have become so rare.

The incidence of bulimia nervosa rose in 1992, the year in which journalist Andrew Morton exposed Princess Diana’s ‘secret disease’, and peaked in 1995, when she revealed her eating disorder to the public. It began to decline in 1997, the year of her tragic death. This synchronology suggests that Princess Diana’s status and glamour combined with intense press coverage of her bulimia and bulimia in general led to an increase in the incidence of the disorder.

An alternative explanation is that Princess Diana’s example encouraged people to come forward and admit to their eating disorder. By the same token, it could have been that the Japanese had always suffered from depression, but had been hiding it, or had not had a template by which to recognize or externalize it. The danger for us psychiatrists and health professionals when treating people with mental disorder is to treat the template without addressing or even acknowledging the very real distress that lies beneath.