Transcription
How would you talk about narcissism in NPD? Have you reformulated that as well in your process of rethinking about BPD?
Yeah, I think I went through my own developmental um learning curve. I remember one dinner I went to at the American Psychiatric Association, people were literally screaming at each other about this question of whether or not personality functions as categories of Personality Disorder or whether personality functioned along dimensions that we all have different degrees of these personality features. And I've come to move from one side, the categorical side, to being more in the middle. I still believe that BPD is a category in and of itself. It's when there is such severity that there's broad dysfunctioning that's very painful, lifethreatening, and needs specific intervention. But I think all the other personality disorders may be more continuous with the exception of perhaps antisocial and schizotypal because there's more evidence behind the biology of those disorders. The jury's still out on that.
But when it comes to narcissistic personality disorder, I've really changed my mind. I used to really recognize the constellation of features in the diagnostic statistical manual in patients. So it's a real thing. I'm not denying that people turn out with that specific set of characteristics. Some do, and some have variations like dimensions of narcissistic problems. And I also feel that everyone has varying degrees of narcissism, and for everyone along their life trajectory, that functions better in some cases and it dysfunctions severely in other cases.
MH, so for example, I think that when people become new parents, for instance, they don't know what they're doing and they feel completely incompetent over things like changing a diaper, which let's face it, that's actually not that hard. But you feel like you don't know what you're doing, like you're a baby learning how to do something for the first time. And that causes a real crisis of self-esteem. Can I do this? Am I capable? Am I good enough? And that happens to most parents. I think parents who don't have that happen, I think there's something wrong with them. But over time, you know, all those jokes, how with the second child, you like sling them on your hip without any diaper bag and you just go. Um, that is development for you. That's learning. That's gaining confidence through experience.
So I actually think narcissism is a universal factor in personality functioning. And yet we focus on these parts of narcissism that might actually not be that clinically important. There's a grandiose side of narcissism, which might be narcissism's calling card when someone has these like grand ideas and like everything's like over the top and the best and go big or go home. I have to admit, I'm a little bit like that. That side is like the signature of narcissism. Whereas the vulnerable side of narcissism has to do with the need to get assurance and attention and be positively regarded and worry about all of that. That's actually the part that gets people into clinically focused situations. That's what makes them depressed. That's what gets them hospitalized. That's what makes them suicidal. So it's actually not this thing about narcissism, the grandiosity, that's really necessarily the problem, but this combination of needing to go big or go home plus this kind of vulnerability. If that doesn't happen, that combines in certain people to make them more likely to have pathological narcissism or disturbances in narcissistic functioning.
There's this variation that is pretty clearly identifiable that's described in the DSM that does describe some people, but not everyone who meets those criteria have significant distress and dysfunction. So they don't actually meet the bar for qualifying for a personality disorder. You could have those qualities and become like these tech magnates who transform the way we do commerce or change the way we think about electricity. I mean, these are qualities that are not necessarily going to make someone disabled.
Yeah, the reason I think grandiosity is really misunderstood is that all young people need a bit of grandiosity to leave home. You have to be thinking you can do something that you can't yet do. And for example, like I say to lots of people, yeah, of course I'm grandiose. Why else would I build a residential program with nine people who are suicidal or self-destructively having severe symptoms of borderline personality disorder and think that would be a manageable thing? It took a bit of grandiosity and not knowing what we were getting ourselves into to have the motivation to do it and keep doing it. So there are a lot of good things that come out of grandiosity. There's a lot of good things that come out of paranoia. There are a lot of good things that come out of perfectionism. But the problem is when the person or the operator, the personality, doesn't apply it in a way that uses their frontal capacities, that is the evaluating, planning, strategizing capacities of the brain.
Personality functioning and personality traits really have to take what's inside, like what we're feeling, thinking, wanting, worried about, and then somehow translate that into what you do in the outside world. And that process is super complex. It's a lot more complicated and dynamic than other areas that we focus on in psychiatry. Like I think mood is a very complex entity, as is anxiety. But personality combines all of that with relationships, behaviors, and identity. So, um, what could be more interesting than that?