When narcissism becomes pathological

Amy and Rob had been married for four years the day he turned a gun on her. Their relationship had been turbulent from the outset, but by 2005 their farm was failing, and, Amy says, “We were in so much debt it was unbelievable.” There were other, more serious problems: Rob would frequently tell the children they were lazy, stupid and ignorant, and he had threatened to kill his father. One night, Rob flew into a rage, screaming and cursing his wife. Amy told the kids to get their things together, because they were leaving. While the eldest two went to their room, Amy picked up her youngest, and went to the bedroom to gather some of his things.

“Then the door flew open,” she recalls, “and Rob was standing there with the shotgun. He closed the bedroom door and told me that he would kill me if I tried to leave with the kids. I told him that I would not be going alone; that if he wanted to shoot me he would get shot himself.”

No one shot anyone. Amy calmly reached for her mobile and called her father. “He said he was coming over, and Rob backed out of the bedroom.” Rob denied threatening to kill his wife, and the charges were eventually dropped. But as the divorce wound its way through the courts, a social services report diagnosed Rob with narcissistic personality disorder. In preparing to leave the farm with their children, Amy had threatened to take from her husband the one thing he couldn’t live without. It wasn’t love, or sex, or his family. Rob couldn’t accept a life in which he wasn’t the centre of attention.

Narcissistic personality disorder (NPD) is a form of pathological narcissism, first diagnosed by the psychoanalyst Heinz Kohut, in 1968. A rigid pattern of behaviour that drives a lifelong quest for self-gratification, NPD is characterised by a grandiose sense of self-importance, an insatiable need for attention and a chronic lack of empathy. (See the box on page 30 for a full list of symptoms.)

NPD is classified as a cluster B (or “dramatic”) disorder, alongside antisocial and histrionic disorders. (Cluster As, or “odd” disorders, include paranoid and schizoid disorders; cluster Cs, or “anxious”, include dependent and obsessive-compulsive disorders.) Today, experts believe disproportionate numbers of pathological narcissists are at work in the most influential reaches of society. As Sam Vaknin, author of Malignant Self-Love, a bestselling study of narcissism, says: “Narcissists gravitate towards professions where they can control people and elicit adulation. They are more likely to work in politics, finance or medicine than in shoemaking.”

The disorder, formerly known as megalomania, affects 1 per cent of the population and up to 16 per cent of the clinical population. It is not easily discernible to the untrained eye, partly because a degree of self-love is essentially healthy: it protects us from self-harm; it enables us to form support networks, to find a mate and procreate. NPD, however, is not simply a healthy self-regard gone astray.

Jose Romero-Urcelay is a forensic psychiatrist and the director of therapies at the Dangerous and Severe Personality Disorders unit at Broadmoor, West London Mental Health Trust. He confirms Vaknin’s theory that pathological narcissists are drawn to careers in finance, law and politics. He also treats numerous patients with narcissistic personality disorder. “It is crucial,” he says, “to distinguish between narcissistic traits, which may be advantageous – such as confidence, a need to get to the top, the need for praise – and NPD. Those with personality disorders are exploitative, and likely to cause significant distress to others.”

Typically, this takes the form of emotional abuse. The narcissist’s insatiable quest for attention (what Vaknin was the first to describe as “narcissistic supply”), leads him or her to seek out a steady source of admiration. Where that is in short supply, the narcissist prefers to inspire fear or hatred than suffer the nightmare of being ignored. And unable to empathise, they are indifferent to the consequences of hurting people.

NPD alone is seldom the trigger for violence; this tends to arise when it is co-morbid – ie, it co-exists with another personality disorder, often histrionic or paranoid disorders. But the case of Rob and Amy is far from isolated.

In 2005, Brian Blackwell, a promising student from Merseyside, was sentenced to life for killing his parents. Blackwell, then 19, had bludgeoned his mother and father to death with a claw hammer, and stabbed them repeatedly with a kitchen knife. He then left them to decompose in their living room while he took off on holiday to America with his girlfriend and his parents’ credit cards.

Blackwell pleaded guilty to manslaughter on the grounds of diminished responsibility. His lawyers argued that he had NPD, pointing to his fantasy lifestyle (Blackwell claimed to be a professional tennis player) and the swaggering sense of power that persuaded him to return from the US to collect his A-level results (four As) even as the smell from his parents’ rotting bodies was drawing worried neighbours to their door.

The police were at a loss to understand Blackwell’s motive for killing his loving parents. But experts believe that NPD patients are dysfunctional and immature, and that to compensate for this inner, sick child the narcissist invents a fiction – that they are omniscient, or omnipotent.

This delusional sense of power appears to have afflicted Raoul Moat, who earlier this summer shot his ex-girlfriend and killed her new partner, before going on the run – later shooting a policeman and killing himself. Moat was never diagnosed with NPD, but David Wilson, professor of criminology at Birmingham City University, has labelled him “one of the best examples of a narcissist we will ever encounter”. Indeed, Northumbria police, suspecting they were on the trail of a narcissist, admitted appealing to Moat’s vanity by paying tribute to his outdoor survival skills and his ability to evade their dragnet, as well as reassuring him that he had a future.

Moat had a record of steroid abuse, and had appealed for psychiatric help. His ability to function to the extent he did, and, in his own mind, thrive – possibly triumph – in his confrontation with the police may have been sustained by pathological narcissism. For, according to Sam Vaknin, it is the narcissism that allows a person with NPD to function, “because it is adaptive: it’s a set of defence mechanisms that compensates for the narcissist’s deficiencies”.

Vaknin ought to know. The former owner of Israel’s largest stock exchange brokerage house is, in his own words, a “pure-bred narcissist”, and has twice been diagnosed with NPD. In 1985, while working in the City of London, he submitted himself for diagnosis, because “I wanted to understand why I was destroying my relationship with my fiancée.”

Vaknin was in his mid-twenties and a self-made millionaire. He was also heavily into group sex and voyeurism. His moods swung between attacks of rage and obsequiousness. And, he says, “I was haughty, fake and nouveau riche.” When his psychiatrist concluded that Vaknin had NPD “I had no idea what he was talking about,” he says. “I tried to corrupt him, I offered him money, and having felt that I succeeded, I lost all interest in him.”

Vaknin’s relationship with his fiancée petered out, but his appetite for high-risk rewards did not. In 1995, he was arrested for securities fraud in his native Israel, and sent to prison near Tel Aviv. The following year, Vaknin agreed to be assessed by a mental health expert, as a condition of his parole. He was diagnosed with various personality disorders. “I was borderline schizoid, but the most dominant was NPD,” he says. “It was a relief to know what I had.”

In the mid-1990s, public awareness of NPD was virtually non-existent. Nonetheless, Vaknin says his diagnosis “explained fully, without exception: everything from my style of speech to my relationships. This time I knew: this is it.”

Since his release from prison 14 years ago, Vaknin has communicated over the internet with tens of thousands of narcissists and their victims. Few people can claim to have increased the public awareness of NPD to such a degree. Today, his website receives five million users a year. “Not bad, huh?” he says. “You see, I have leveraged my narcissism: I have lived on the proceeds of my book for 15 years. What would I have been without my illness? Another businessman?”

Nonetheless, Vaknin is on controversial ground with some of his theories. The most contentious is that narcissists are akin to a form of artificial intelligence: “Intelligent,” he says, “because most narcissists are. And artificial, because they lack empathy, the ability to relate to other human beings. Academics will tell you that I am wrong; they will say ‘No, narcissists are people.’ This is bull.”

NPD is the bastard child of personality disorders. “No one knows where it comes from,” says Jose Romero-Urcelay, “but it tends to present in the patient’s early twenties.” There is no genetic predisposition to the disorder, nor are specific types of people more susceptible than others. It isn’t triggered by illness, injury or substance abuse. Some suspect it may be caused by an excess of love in infancy; others by childhood abuse or emotional trauma. Some point to a breakdown in the infant’s relationship with his or her mother.

One thing is clear, though: NPD is more common among men than women. According to Romero-Urcelay, this may be because the traditional male instincts – power, aggression, a hunger for adulation – are more amenable to narcissism. But with gender models changing, there is no known reason why women won’t succumb to the disorder in greater numbers.

Certainly NPD is thriving in western societies. Increased materialism, the decline of community life and a fascination with image afford perfect conditions for its growth. Similarly, our culture increasingly celebrates attention-seeking behaviours. (In July, David Cameron used Prime Minister’s Questions to appeal to Facebook users to take down their “Raoul Moat is a legend” page. “I cannot understand any wave, however small, of public sympathy for this man,” he said.)

But while those on the left might seek to explain the increase in NPD by looking to Margaret Thatcher’s infamous claim that “there is no such thing as society” – and then to Emile Durkheim’s theory that sick or failing societies breed pathologies – sociologists are by no means unanimous that western culture is a greenhouse for pathological narcissism.

“It’s not clear-cut that society as a whole is more individualistic than, say, 20 years ago,” says Dr Martyn Pickersgill, a sociologist at the University of Edinburgh. “You can see all these new mechanisms of community, from Facebook to more overt activism. In mental healthcare you have a number of grass-roots groups. This is a reaction against individualism.”

Sociologists are also sensitive to the pressure from drug companies to medicalise different categories of people. “In general, we can see more of a ‘psychiatrisation’ of society,” says Pickersgill. “Many people more broadly see themselves and each other in terms of psychiatric categories.”

It’s a trend mapped out in alarming detail by Emily Martin in her recent book Bipolar Expeditions. Martin, an American anthropologist, describes how mania has come to be regarded as the new American frontier – one that attracts clinical pioneers with the promise of fame and fortune.

“Sometimes, as clinicians, we project our diagnoses on to patients,” says Romero-Urcelay. “NPD can be misdiagnosed.”

It is widely anticipated that the next edition of the influential Diagnostic and Statistical Manual of Mental Disorders, due out in 2014/15, will reclassify NPD from a standalone disorder to one that presents only alongside other personality disorders. How will narcissists feel about this?

“Pathological narcissism is not a pure diagnostic category,” says Vaknin. “It is like taking temperature: you have a temperature present in so many diseases and illnesses, but you can’t diagnose someone with ‘temperature’.”

It is, perhaps, not surprising that clinicians are still grappling with NPD. Even the people who live with narcissists can take years to spot the symptoms. “Victims don’t see a pattern of abuse in their narcissistic partner,” Alice says, “because there’s nothing wrong with them. It’s your fault.”

A victim herself, Alice is in her thirties and works in the City of London. She grew up in New England and suffered at the hands of her narcissist mother for much of her adolescence. From the time Alice was two years old, her mother was largely absent from her life. “She was chasing her boyfriend all over the world,” she remembers, at her home in Surrey. “Mum had me, and my brothers and sisters, and my Dad. But the boyfriend was her narcissistic supply.”

In the absence of her mother, Alice was raised in a loving, patriarchal family. Crucially, she says: “My mum didn’t have much chance to abuse me during the first nine years of my life, because she didn’t have to – she wasn’t there.”

But when she returned home to New England, Alice’s mother began to seek a supplementary supply: her discarded family. The problem was Alice. She was maturing into a bright and pretty nine-year-old, and her popularity infuriated her mother. “I had a high IQ, morals, values,” Alice says. “I was the adult in our relationship, and that looked bad in front of her friends.”

While the narcissist’s need for “supply” is inexhaustible, their sources are not. Devoid of empathy, narcissists will escalate the drama of a situation – regardless of whether the attention is positive or negative, it is simply more attention. As Alice realised as a child, “Nothing says to a narcissist mother ‘You are really important to me’ like the sight of their own child in a heap, crying, because of what mother has done.”

Overshadowed by her youngest daughter, Alice’s mother began to turn her siblings against their sister. “A narcissist can be covert in their abuse,” Alice says, “and my Mum used my siblings as her ‘enablers’. Children will compete for love, and there was no love coming from my mother, so they began to pick on me.” She shrugs. “They were only trying to survive.”

By 14, Alice had had enough. Her mother was ready to drag her overseas. “I said, ‘Mum, there’s a really good boarding school down the road. You know what… you go and I’ll stay here’. She came back and threw me out at 18.”

Did you ever sit down and explain that she was damaging your life? “No,” Alice laughs, “there was no point. There was nothing wrong with her!”

Alice regained her self-esteem in her mid-twenties – initially at university, and then by moving to London and working her way up through the City. She claims to have spotted a high level of pathological narcissists in the financial sector (“in hedge funds, more than anywhere else”) and mentions a friend who I should talk to.

She is a recruitment consultant for City companies and actively profiles for narcissists. Unsurprisingly, she was reluctant to talk to the FT. But as Alice explains, “Narcissists are prime candidates in finance, because they are able to make quick, bold decisions without any thought for the consequences these might have on other people.”

Despite her abusive childhood, Alice was unable to spot similar traits in her husband. It is not uncommon for the victims of narcissists to be drawn to successive abusers – experts label these repeat victims Co-Ns. So what attracted Alice to a narcissist partner? After a lengthy pause she smiles. “Me,” she says, ruefully. “Narcissists are empty vessels; they reflect back your personality so as to attract you. They try to make you think you’re their soul mate.”

Alice’s marriage hobbled along for 12 years. Her husband’s abuse was unrelenting. He spent much of a fortnight’s family holiday texting his mistresses. He flew into a rage when, two weeks after giving birth, she had still not returned to work to support his business venture. He would humiliate her in front of friends and strangers.

Eventually, Alice realised that she had to leave, “otherwise I would be conditioning my daughter to accept a narcissist as a partner, and my son to emulate his father. I couldn’t do that.”

Alice was unable to persuade either her mother or husband to seek proper diagnosis. But while Romero-Urcelay and Vaknin caution against self-diagnosis, Alice is extremely intelligent, and has spent many years researching her ordeal. “It’s a huge comfort to know it’s NPD,” she says. “You realise it’s not you that’s the problem. It’s like being reborn.”

There is no cure for narcissistic personality disorder, and while projections of its growth would be purely speculative, Jose Romero-Urcelay fears that an increase in diagnoses will not be matched by treatment: the healthcare sector currently lacks the experience and resources.

At present, the preferred treatment for NPD is psychological therapies, from individual psychodynamic and cognitive behavioural treatments to group, family and marital therapy. Sam Vaknin believes the emphasis in therapy is more on accommodating the needs of the narcissist’s spouse, children, colleagues and friends than on treating the narcissist. “If the narcissist’s behaviours are modified, those around him benefit most,” Vaknin argues. “This is a form of social engineering.”

So what of the patient? Is he or she not a victim too?

One night, an e-mail drops into my inbox from Wayne – a motorbike courier in Utah, and a self-diagnosed pathological narcissist. His e-mail makes plaintive reading. “I am more scared than at any other time in my life because of the way I am with people,” he tells me. “When I’m making deliveries on my bike, people look me in the eye to try to make a connection, but with me, there is none. I am proud and mean, and most of them find me very rude and disappointing. I can’t help it, but I have just ruined their day by visiting them.”

At 23, Wayne is coming to terms with an abusive childhood, but he can’t stop humiliating people: he relishes the power he gets from intimidating friends and colleagues. He says he wants help, but in America help costs money. Wayne feels trapped: “Parts of me want to have love, friendships, or relationships, but the other parts will not let me,” he says. “So it seems that only through my narcissism am I able to feel somewhat alive, or to have these things.”

Wayne says he frequently contemplates suicide. “It’s just self-pity, though – a thought that takes away from the pain I feel when there is an absence of supply.”

Both Wayne and Sam Vaknin are disarmingly candid, and, in their different ways, reveal a hint of vulnerability. Is there hope for people such as Wayne – narcissists with a critical self-awareness, and a longing for love? Not according to Vaknin. “I understand my condition fully,” he says, “but I’m as virulently narcissistic as I’ve ever been.”

Romero-Urcelay insists that Wayne should seek proper medical help. But in both Wayne and Vaknin I detect a faint glimmer. There is an intelligence, isn’t there?

“Narcissists are robotic,” Vaknin bats back. But what of the self-reproach – that, surely, belies an emotional honesty; room, perhaps, for the love of another. “It’s a calculated honesty,” Vaknin says, without missing a beat. “I am a pathological narcissist. I need attention. Everything I do is calculated.”

Some names and details have been changed

Adrian Tempany is a freelance writer. His last piece for the magazine was about palliative care teams. Read it at www.ft.com/palliative

NPD – the diagnosis

A victim of narcissistic personality disorder will exhibit at least five of the following traits

1. A grandiose sense of self-importance

2. A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love

3. A belief that he or she is “special” and can only be understood by, or should associate with, other special or high-status people (or institutions)

4. A requirement for excessive admiration

5. A sense of entitlement – unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations

6. Interpersonal exploitativeness – taking advantage of others to achieve his or her own ends

7. A lack of empathy and an unwillingness to recognise or identify with the feelings and needs of others

8. Enviousness of others – along with the belief that others are envious of him or her

9. A tendency to arrogant, haughty behaviours or attitudes

Source: Diagnostic and Statistical Manual of Mental Disorders IV

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