Narcissistic disorders in clinical practice

In this paper, the concept of narcissism in the psychoanalytic literature is reviewed and three uses of the term are defined, firstly, clinical narcissism, secondly, an innate force or tendency opposed to relationships and thirdly, narcissistic personality disorders. The latter can be further differentiated on the basis of the transference/countertransference into borderline (thin-skinned), aloof (thick-skinned) and as-if (false-self) narcissistic disorders. The characteristics of each of these patterns are described. The author suggests that narcissistic disorders arise when there is a failure of containment in infancy and childhood that gives rise to an ego-destructive super-ego leading to the evolving of a narcissistic organization. The libidinal defensive organization arises when parental failure of containment is the primary factor and destructive organization when the infant has an excess of object-hostility. Two case descriptions are given to illustrate the distinction between a predominantly destructive and a predominantly libidinal narcissistic disorder and the author suggests that both arise from the production, by projective identification, of a narcissistic relationship with an ego ideal in order to evade a relationship with a destructive parental super-ego.