On the uses and abuses of narcissism as a public health issue

Summary

Psychiatry understands narcissism as a pathological condition associated with poor social outcomes and difficulty relating to others. Millennials have been depicted by psychological research as ‘narcissistic’, and the term has lost accurate meaning. We underline the intellectual laxity of conflating social changes with narcissism and suggest ways forward.

In this paper, we argue that social psychological research into narcissism may be creating a fictitious problem and expecting others to solve it. The misuse of the term in the public consciousness has created a pathological label that is now used routinely to describe and dismiss individuals who appear self-serving, squeezing out the important causal and clinical detail that the term ‘narcissism’ provides into a simple stigma. After summarising the literature on narcissism, we contend that it is important from a public health perspective that this term is reclaimed and, in the face of mounting confusion and distortion as well as efforts to remove it from clinical parlance, repurposed in clinical and research work.

The evidence base

If societies were going to be psychologically profiled on the basis of the spread of current popular psychological research, then the assessment would be worrying: they are narcissistic, and new generations are becoming ever more so. Books on the rise of entitlement and an ‘epidemic’ of narcissistic traits,¹ coupled with rising rates of diagnosis of narcissistic personality disorder among millennials (those born between the late 1980s and mid 1990s),² sell thousands and stimulate debate about major shifts in core personality traits between generations. These researchers conclude that this is a negative shift, linking the rise in narcissism to increases in anxiety, depression, stress and suicide.

How do social psychologists conclude that we face an epidemic of narcissism? By looking at responses to Raskin & Hall's³ Narcissistic Personality Inventory (NPI) from 1979 to 2006, Twenge et al⁴ found that approximately two-thirds of college students in 2006 scored above the mean on the NPI, compared with approximately half between the years 1979 and 1985. In fact, the work by Twenge and others has been vehemently criticised by other researchers, notably those from the clinical psychology community, on problematic statistical and methodological grounds⁵ and the use of measures not intended to assess pathological narcissism.⁶ Moreover, any differences that have been found may be age effects, since narcissism as a trait mutes with age.⁷

Clinical research cautions on two points. First, conceptualising narcissistic personality disorder has been notoriously difficult. Currently, narcissistic personality disorder is absent from some official diagnostic classification systems for mental disorders (e.g. ICD-10) and anathema to modern formulations of personality disorder that eschew stigmatising language.⁸ Also, when it has been conceptualised, it appears to have two subtypes with different clinical features:⁹ one is characterised by grandiosity and linked to psychopathy, the other by vulnerability and introversion and linked to anxiety and childhood maltreatment. Second, the prevalence of narcissism as a personality disorder is ‘remarkably low’, with some studies finding 0% prevalence in the adult population and a systematic review finding a weighted average of 0.26% of the population.¹⁰ Even when compared with other personality disorders, such as borderline personality disorder, which affects around 1.6% of the population at any one time,¹¹ this is a low proportion; however, it may be underreported because of narcissistic personality disorder's absence from ICD-10 and problems with accurate screening measures. Some high-quality studies (e.g. Stinson et al¹²), have found a higher lifetime prevalence of narcissistic personality disorder in the general population of up to 6.2%, but these studies have been exclusively conducted in the USA and not replicated elsewhere.

Narcissism: serious pathology, not a serious public health issue

In psychoanalytic thinking, a degree of self-love is required for healthy development, since the child learns about love through, initially, love of themselves. It is only when this process is disrupted through inconsistent or extremely overvalued parenting that this narcissism develops pathological features, as described by Heinz Kohut.¹³ Otherwise, it is precisely through this ‘healthy’ self-love, or self-esteem, that the child has a secure base to form attachments and later intimate relationships with others. Indeed, low self-esteem among adolescents has been shown to independently predict poor health, criminality and low socioeconomic status.¹⁴

However, for Kohut, there are serious psychological consequences to overdevelopment of the self-love impulse. Through unempathic and inconsistent parental interactions (what Kohut specifically calls the ‘mirroring’ of emotional cues), the infant's self-love comes to replace the love of others around them, which is itself underdeveloped and neglected. In this case, the child develops into an adult for whom other people are merely instruments to be used in the gratification of their own ends: they lack interest in others and believe themselves unique and special, with an incongruous sense of their own abilities, yet entitled to reward for their work, regardless of merit.

The later work of Otto Kernberg further developed this developmental aetiology by proposing that, rather than failing to develop enough love for others, the narcissist forms ambivalent and negative conceptions of themselves and the ‘other’, and when the environment or other people do not perform to the narcissist's impossibly high expectations, this triggers intense narcissistic rage.¹⁵ Thus, the narcissist tends to devalue others at their expense and to cultivate an intense form of self-love so as never to be dismayed by the failings of the other. However, by either mechanism, the resulting condition is referred to in DSM-5 as narcissistic personality disorder; it does not have a diagnostic parent in ICD-10 or ICD-11,⁸ where these traits are instead considered evidence of ‘dissocial’ personality.

Despite disagreement about the precise nature of the diagnosis, there is consensus that narcissistic personality disorder is a deeply pathological condition representing significant personality disturbance and associated with serious adverse consequences for individuals meeting the diagnostic criteria, including: lifetime unmarried status; drug and alcohol dependence;¹⁵ anxiety disorder;¹² and elevated risk of coronary heart disease.¹⁶ Factoring in the ‘collateral’ impact of what has been called ‘narcissistic perversion’ on others, it is plausible to consider narcissistic personality disorder to be a public health concern because of its impact on both those diagnosed in this way and their social circles, particularly intimate partners.

Attention in the public eye to men who make use of their positions of power to control and manipulate others into providing sexual gratification has also rekindled lay and clinical curiosity into the idea of the narcissistic pervert. Such a person will systematically ‘morally harass’ those close to them to obtain compliance through breaking down their sense of self.¹⁷ We have new words for this behaviour now – ‘gaslighting’, ‘ghosting’ and ‘benching’, depending on the exact method used – but in every case it is the narcissist's perverse need for absolute power and impunity in relationships that drives the activity. However, there is an important distinction to be maintained between a personality disorder as a medical condition, pathological or subclinical narcissism⁶ and simple ‘mean’ behaviour. Without understanding the motivations behind behaviour, whether compulsive selfie-posting or abuse, it is impossible to infer a narcissistic personality structure, let alone a clinical disorder.

Narcissism as a concept has also been applied to group and organisational behaviour where an organisation is overtly committed to legitimising its identity through the attributes it steadfastly holds, rather than accountability to the public or stakeholders. Psychoanalytic approaches to understanding organisations make a connection between disparate aspects of organised activity, such as rationalisation, denial, self-aggrandisement or sense of entitlement.¹⁸ Often organisational narcissism is personified through its leadership or the ‘narcissistic CEOs’ seeking inflated views of themselves or to have these continuously reinforced.¹⁹

Generations and nations of narcissists

The 5-item Collective Narcissism Scale (CNS) has been used to assess the association between potentially nationalistic views that feature as more narcissistic on the scale and affiliations with political parties in the USA.²⁰ As an alternative, Campbell and colleagues²¹ developed a methodology to assess perceptions of the national character of the USA and found a relationship with narcissistic personality disorder. Studies designed to assess narcissism at societal levels face the same problems as those examining generational patterns of narcissism, and there are concerns regarding the reliability and validity of findings based on scales such as the CNS and NPI.

When comparing social/personality psychologists’ and clinicians’ conceptualisations of narcissism, there are clear disciplinary differences and limited consensus regarding the vulnerable features of narcissism and the relevance of self-esteem.²² However, the onus remains on researchers to show that a rise in narcissistic traits is causally related to poor health outcomes and not a natural and healthy adaptation to an increasingly unequal, individualised society (which incidentally has negative consequences for mental health). This is correlation masquerading as causality. It may even be that reverse causality is at play: that these negative outcomes derive from social changes and that some increase in trait narcissism is a functional response at the population level to increasing demands of work and decreasing social resources.

Social drivers for self-obsession

With the intense incorporation of social media and information and communications technology into our everyday lives, the notion of narcissism is closely aligned with composing and narrating ourselves through personal devices such as the smartphone and digital platforms online, particularly social networking and profile creation. These mobile technologies enable us to image and narrate ourselves through the screen and, with the gaze of others, renew our infant obsession with the self. To constantly curate our identities for a screen culture is perceived as unleashing a screen-augmented narcissism where the self is commodified as an entity online.²³ Today, an online presence is seen as a vital composition of our identity formation but this need not mean consigning the formation and maintenance of it as an obsession with ourselves. Understanding the process of curation of ourselves through the premise of narcissism alone can be a limiting exercise and a potentially damaging one.

There is an acute and renewed consciousness of a ‘screen self’ or a self mediated through interactive technologies. This has led to a need to manage the screen self online and to be conscious of how we are represented or consumed by a wider community of peers and unknown strangers. While this may have led to intense anxieties about managing the representation of the self online, conflation of these technologically mediated transactions of the self with narcissism may be overly limited. It neglects the complex interplay of identity, social processes and presentational strategies that we appropriate in different contexts offline.

The colloquial experience of ‘narcissism’ in society, understood as a kind of obsessional identity curation, appears to be well captured by social and personality-based psychological research. However, research has not reliably found the link between online identity curation and narcissism.²⁴ Patterns of selfie-posting have shown a correlation with some constructs of narcissism in men;²⁵ but the ‘selfie generation’ are not the same clinical narcissists that psychiatrists are taught to treat. Rather than a core belief in the primacy of the self over others, teenagers’ filter-heavy Instagram accounts might betray the opposite: a quest to find self-belief in the face of deep uncertainty about the nature of the current global situation and their place within it.

Problematising narcissism

If we accept the argument from social psychology that the management of the online self is indeed a rise in the prevalence of problematic narcissism rather than simply a rise in self-promotion, one would expect an associated rise in the prevalence of narcissistic personality disorder diagnoses and a burgeoning critical mass of research into the topic; however, there is no evidence for this.⁵ Many have acknowledged the paucity of actual empirical work on narcissistic personality disorder in the clinical literature, and there has been considerable discussion of the validity (or lack thereof) of the measures that are used to assess the presence of this personality disorder.²⁶ ‘True’ narcissistic personality disorder remains vanishingly rare – literally so, owing to its non-presence in clinical epidemiology – and the diagnosis itself is now on the road to obsolescence after the ICD-11 revisions to the nosology of personality disorder.

At the same time, the work of social and personality research has consolidated complex patterns of experiences in society and culture into a convenient term, ‘narcissism’, that expresses a moral panic about the erosion of communal beliefs in favour of individualism and, by then conflating trait with disorder, psychologists can point to psychiatrists for the solution. Worse yet, the use of the term has resulted in the lazy pathologising of self-curation judged to be excessive on behalf of everyone, from celebrities, who in some cases have a diagnosed severe mental illness, to populist politicians.²⁷ Any category that can be applied so broadly to such a wide range of people has clearly lost its ‘ground truth’: the underlying accuracy of the term.

It could be argued that this is part of a broader tendency of popular science and the media to co-opt tropes from psychiatry to explain away complex social tensions and challenges. Narcissism, in particular the ‘deficit’ model proposed by Kohut, presents an easy scapegoat for a breakdown in trust and dialogue between generations driven by legitimate existential and ecological concerns, and shifts the burden of resolution away from policy and open debate onto psychiatrists and other mental health professionals. This is reminiscent of Thomas Szasz's argument, made in the 1970s, that a dialogue about mental illness can conveniently scapegoat elements of society (homosexuals, drug users) that deviate from the established ‘moral order’;²⁸ only in this case an entire generation of young people, at least in the West, is apparently subject to this stigmatisation.

Conclusions

It is possible that obsessional identity curation is a basis for a degree of concern and even a burgeoning moral panic that the rising commitment to the online ‘screen self’ will have negative consequences for social cohesion and well-being. It is also possible, and evidenced, that this obsession is more common among younger people. However, the use of clinical language such as narcissism to depict this concern in the public gaze is lazy and intellectually misguided, irrespective of the quality of the scientific enquiry informing it. When the concept of narcissism is reduced to a simple insult, we lose the purpose of the clinical term, which was value-neutral and referred to the outcome of a developmental process indicating suffering and a grossly deficient emotional experience of the world, with considerable consequences for that individual's physical and psychological well-being, including the potential for suicide through narcissistic destabilisation.²⁹ In other words: someone deserving of help and sympathy, not dismissal or stigma.

How then to address this issue? We argue that this is a case for both public education and a major rethink by social psychology. First, social psychologists demonstrating a rise in clinical characteristics from behavioural research need to accept that a far higher burden of proof is needed to persuade medical researchers of this rise. Clinically speaking, excessive self-promotion could be a sign of any number of conditions, of which narcissism is only one – and an unlikely one at that. Bipolar disorder, obsessive–compulsive disorder and other forms of personality disorder are all related to self-esteem and all have far higher prevalence rates than narcissism, and yet no effort has been made to explore whether these constructs are a better ‘fit’ for a rise in selfie-posting. Second, clinical experts – whether psychiatrists or psychologists – need to rearticulate the functional value of narcissism as a construct, including consulting with patients who have attracted this diagnosis. As a potential blueprint for this we would suggest the success of the recent co-production of a consensus statement for the related condition of borderline personality disorder in integrating patient, clinical and research perspectives on an issue.³⁰