Levels of adaptation and narcissistic psychopathology

Why, one might reasonably query, do some narcissistic characters serve time as seemingly successful presidents of corporations while others serve time as seemingly impaired inpatients on psychiatric units? I will offer some observations on this unusual clinical phenomenon and suggest that it is useful to distinguish between two clinical presentations of narcissistic character psychopathology, which I will call, for the sake of expedience, Level 1 and Level 2. I will then examine 1) how an understanding of the dimensions of empathic abilities, paranoia, levels of depression, grandiosity, and defensive uses of denial and disavowal can lend a broad explanatory range to the understanding of these levels, and 2) how we can assess both successful and unsuccessful adaptation to the outer world and the inner world in narcissistic disorders. Moreover, it is important to distinguish between being well adapted and being emotionally healthy, which are quite different in meaning and intent. I use the term Level 1 to refer to the more poorly adapted presentation, and the term Level 2 to refer to the more successfully adapted narcissistic presentation. Characteristics of Level 1 narcissistic pathology dispose a patient to an adaptation that is similar to the description of the narcissistic patient who is often described as borderline; characteristics of Level 2 narcissistic pathology dispose a patient to a high-flying and superficially successful adaptation in which the patient can competently navigate the occupational and social demands of an external world despite the presence of severe object relational impairments. While a difference in adaptation is highlighted, emotional well-being is not within the exclusive province of either's characteristic adaptive skills.