Fink! Still at Large: Low Self-Esteem and Narcissism. (Opinion)

Article excerpt

New research by Brad J. Bushman, Ph.D., and Roy F. Baumcister, Ph.D., in the Journal of Research in Personality shows that people with a high self-regard--specifically, narcissists-are more likely to lash out aggressively when criticized than their counterparts.

In fact, this study suggests that narcissism in a patient rather than low self-esteem is actually an important cause of aggression.

For Discussion: Is the notion that bolstering the self-regard of patients can lead to positive behavior a useful one? How often have you found yourself addressing the issue of narcissism among your patients? What approach works for such patients in your practice?

'Malignant Narcissism'

For some years I have suspected the existence of a subtype of Narcissistic Personality Disorder (NPD), which I have referred to as "malignant narcissism," manifested by aggressively lashing out at critics. These individuals frequently display the same sense of entitlement usually associated with NPD, but such aggressivity seems most commonly associated with those who are interpersonally exploitative.

As interpersonal exploitation is only one of nine possible diagnostic criteria for NPD (five are required), I do not believe that bolstering the self-regard of a patient necessarily results in an aggressive patient. It may well, however, result in a more assertive patient--often a desirable consequence.

In addressing malignant narcissism, my intervention of choice is confrontation. As I am a forensic psychiatrist and a former trial lawyer, I recognize that this may reflect a personal bias.

Daniel W Hardy, M.D., J.D.

Elgin, Ill.

Many Factors Are Involved

I hope and trust the authors were not suggesting that there is just one cause of violence and aggression. An enormous body of scientific and historic evidence demonstrates that many factors-biologic, psychological, and social--additively and interactively contribute to the many forms of violence that continue to plague our world.

Both low self-esteem and its near opposite, pathologic narcissism, certainly can contribute to violence. Sometimes too much and too little may even coexist, as in Freud's example of one of literature's favorite villains: Shakespeare's wounded-therefore-entitled Richard III.

As with many biologic and psychological arrangements, both too little and too much of something can and often does cause trouble. In the case of violence, inadequate and excessive narcissism are both worth study as are attempts at repair and cure; but so also are numerous familiar, tenacious, and relevant biologic, psychological, social, and even political arrangements.

It is nearly certainly wishful, a bit arrogant, and inadequate to view violence as a purely narcissistic, or even as a purely psychiatric, phenomenon.

Lawrence Hartmann, M.D.

Cambridge, Mass.

Dr. Fink: This question reflects a linear approach to such highly charged technical terms like self-esteem and narcissism. These concepts are not very different.

A person with low self-esteem has a deep sense of self-loathing and is often depressed. Such people acquire their low sense of self-worth as they grow up and are made to feel unworthy or inadequate. No matter how hard they try, they just cannot seem to satisfy the other person--mothers father, or spouse--and are always reaching for, but never getting, the gold ring. Woody Allen said he once brought home a paper with a grade of 97 and his father asked him who got the other three points.

Our self-esteem is on a continuum from very low to very high. In the middle, the average person goes through life not paying attention to their sense of themselves. Individuals know what they are good at and what they cannot do and, generally, they are about to assess their worth on what is real. In terms of aggressive responses, it is possible that someone with low self-esteem could attempt to cover up feelings of worthlessness with false bravado or by lashing out at others. …