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May 2017
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The myth
Pathological vanity, or narcissism, is becoming an ever-increasing personality disorder. The origins of this issue are rooted in classical literature, that is, in Greek mythology. In fact, narcissism can be found in the myth about Narcissus, son of Cephissus, God of the river, and Liriope the nymph.
According to this myth, narrated by Ovid in the metamorphoses, Narcissus was a handsome young man with whom men and women alike feel head over heels in love. However, Narcissus preferred to spend his days hunting, oblivious of his admirers, one of which was Echo the nymph, who was condemned by Giunone to repeat every last word that was said to her since she chattered so much that it disturbed the Goddess, thus she missed out on the furtive love of Jupiter. Rejected by Narcissus the nymph, yet consumed by love for him, Echo hid herself in the forest until she disappeared and was just a distance echo. However, it was not only Echo but all the young men and women who were despised by Narcissus who invoked the vengeance of the Gods and, as a result, Narcissus was condemned by Nemesis to fall in love with his reflection in water. Desperate from not being able to satisfy the passion he had for his own reflection, he was consumed with useless complaints, which were repeated by Echo. Realising the impossibility of his love, Narcissus left himself to die. When the naiads and dryads found his body, in order to place it on the funeral pyre, they found a flower near the water mirror with the same name. It is said that Narcissus, when he crossed the River Styx, the river of the dead, to enter his grave, looked into the water still hoping to see his reflection but he could not see anything because of the murky, muddy nature of the water. Ultimately, however, Narcissus was glad he did not see his reflection because it meant that the child, who loved himself, was not dead yet. In the Boeotian version, the young Narcissus, a citizen of Thespiae, was sentenced to love his image when Ameinias, a young man who Narcissus cruelly spurned, committed suicide outside his home with the same sword that Narcissus had sent him as a macabre invitation not to give him more trouble. 
The myth of Narcissus also lives on in the English poet and dramatist William Shakespeare's comedy through the character of Malvolio, who appears to the public to clearly be suffering from an excessive love for himself which is associated with the tendency to take light offenses as devastating attacks.

Phenomenology and psychodynamic understanding
Before moving on from Greek mythology to phenomenology of narcissism, it must said that it is very difficult to grasp the difference between a level of healthy narcissism and a level of pathological narcissism. A certain amount of self-love, self-esteem and self-respect is not just normal but also desirable for everyone. It is not easy, though, to identify the point at which, on a long and imaginary continuum of self-love, healthy vanity becomes pathological. 
What criterion can we use to try to understand this? Without a doubt a person’s life cycle is a very useful indicator; for example, let us consider how we feel towards a teenage boy who spends hours in front of a mirror before going out putting every hair on his head in place: this is quite normal. On the contrary, how would we feel towards a thirty year old man doing the same thing? Perhaps this would not be considered in the same way as the former example. Finally, what about a forty-five year old man who is having a mid-life crisis doing this? This situation could provoke feelings of empathy and understanding for the middle aged man.
Considering and appreciating the culture in which a person is immersed can also help us to assess whether his/her dose of vanity is healthy or not. The Western society is definitely a vain society and the mass media leads us to embrace aesthetics and our image, at the expense of our being, depth and substance, and the fear of getting old and dying are removed and denied in the Western society. If evolutionary differences and cultural influences are valid indicators, healthy and pathological forms of narcissism are nevertheless easy to identify if we consider the quality of a person's object relations. In fact, in the field of interpersonal relationships, some constants which characterise a pathologically vain patient are suffering, emptiness and solitude, which are related to the inability to love.
In cases of interpersonal relationships regarding healthy narcissism, some fundamental characteristics can be identified; for instance, empathy, worry for other people’s feelings, genuine interest in other people’s ideas and the ability to tolerate ambivalence in long lasting relationships, without reaching breaking point, and realising what one’s own contribution to interpersonal conflicts is. On the other hand, regarding pathological vanity, we see the following in sufferers:  they approach others as if they were objects to use and then abandon depending on their vain needs and not caring about the other peoples’ feelings;  they do not consider that other people have separate existences or have their own needs; they often break off a relationship after a short time, usually when the other person starts requesting things.

In psychological literature, many authors have tried to describe the continuum between healthy and pathological narcissism. Amongst these authors are Kohut who described hyper vigilant narcissism, that is, when a vulnerable person tends towards fragmentation of the Self, is very sensitive to other people’s reactions, is inhibited and shy, may even disappear on occasion and avoids being the centre of attention. Kernberg described the unaware narcissist who is jealous, greedy, wants attention and acclaim from others, is not aware of other peoples’ reactions, is arrogant and aggressive and is a ‘transmitter’ not a ‘receiver’. 
Although these types of narcissists can occur in pure form, many individuals show signs of possessing a mix of phenomenological characteristics of both types.

The DSM-IV diagnostic criterion
Diagnosis according to DSM IV – the Diagnostic and Statistical Manual of Mental Disorders - requires that at least five of the following symptoms are present so as to form a pervasive pattern, that is, a pattern that is more or less constant in various situations and relationships:

  1. A grandiose sense of self or exaggerated sense of self-importance;
  2. Being busy with ideas about unlimited success, power, one's effect on others, beauty or ideal love;
  3. Thinking you are "special" and unique and that you can only be understood by other 'special' people, or being excessively worried about being close to someone/being associated with people of very high status in one context or another;
  4. Desiring or requiring excessive admiration;
  5. Having a strong sense of one's own rights and entitlements, being unrealistically convinced that other people/situations have to meet your expectations;
  6. Taking advantage of others to achieve your goals, and feeling no remorse when doing so;
  7. Lacking empathy: the narcissist does not notice or fails to give importance to other peoples' feelings and does not want to identify with their desires;
  8. Feeling envy regularly and generally being convinced that others are envious of him/her;
  9. Being predatory with his/her affections (imbalances of power in relationships, making little personal effort, wanting to receive more than he/she gives, thinking that others are more emotionally involved than he/she is).

How common is narcissism?
According to data from the American Psychiatric Association (APA), narcissistic personality disorder is diagnosable in about 1% of the adult population. However, there are other, higher estimates that put the number between 2-4%. The number of people admitted for this problem is higher though, and ranges from 2-16%. The spread of this disease does not seem ubiquitous, rather it seems to be strongly influenced - at least as far as diffusion goes - by cultural contexts. According to some observers, narcissism is exclusive to Western, capitalised countries. This disorder seems to be influenced by sex and gender too and, in fact, more men are affected by it than women (the percentage being 50-75% of men). Some narcissistic features appear during individual development and this is normal to some degree, especially amongst teenagers and adolescents, for instance.

There are various therapeutic possibilities that patients suffering from narcissism can turn to in order to solve their life problems. For Kohut and Kernberg, psychoanalysis is the treatment of choice for these patients, in order to overcome deficit childhood experiences. However, a supportive and expressive approach, which is less demanding in terms of number of sessions per week and duration of treatment, can also produce favourable results. In some cases, it is desirable to choose a treatment involving individual psychotherapy combined with group therapy. This treatment can be very effective, thanks to the synergy of the depth and intensity offered by the individual relationship and the opportunities it provides to compare and give feedback about group work. Basically, the essential tools of any therapeutic intervention are (thanks the secure environment offered by the setting of work): the building of a positive alliance between the therapist and patient and experiencing and experimenting with new, fuller, evolutionary and satisfying relationship possibilities.

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