Economist Aug 19th 2017
Defenders of President Donald Trump offer two arguments in his favour—that he is a businessman who will curb the excesses of the state; and that he will help America stand tall again by demolishing the politically correct taboos of left-leaning, establishment elites. From the start, these arguments looked like wishful thinking. After Mr Trump’s press conference in New York on August 15th they lie in ruins.
The unscripted remarks were his third attempt to deal with violent clashes in Charlottesville, Virginia, over the weekend. In them the president stepped back from Monday’s—scripted—condemnation of the white supremacists who had marched to protest against the removal of a statue of Robert E. Lee, a Confederate general, and fought with counter-demonstrators, including some from the left. In New York, as his new chief of staff looked on dejected, Mr Trump let rip, stressing once again that there was blame “on both sides”. He left no doubt which of those sides lies closer to his heart.
Mr Trump is not a white supremacist. He repeated his criticism of neo-Nazis and spoke out against the murder of Heather Heyer. Even so, his unsteady response contains a terrible message for Americans. Far from being the saviour of the Republic, their president is politically inept, morally barren and temperamentally unfit for office.
Self-harm. Start with the ineptness. In last year’s presidential election Mr Trump campaigned against the political class to devastating effect. Yet this week he has bungled the simplest of political tests: finding a way to condemn Nazis. Having equivocated at his first press conference on Saturday, Mr Trump said what was needed on Monday and then undid all his good work on Tuesday—briefly uniting Fox News and Mother Jones in their criticism, surely a first. As business leaders started to resign en masse from his advisory panels, the White House disbanded them. Mr Trump did, however, earn the endorsement of David Duke, a former Imperial Wizard of the Ku Klux Klan.
The extreme right will stage more protests across America. Mr Trump has complicated the task of containing their marches and keeping the peace. The harm will spill over into the rest of his agenda, too. His latest press conference was supposed to be about his plans to improve America’s infrastructure, which will require the support of Democrats. He needlessly set back those efforts, as he has so often in the past. “Infrastructure week” in June was drowned out by an investigation into Russian meddling in the election—an investigation Mr Trump helped bring about by firing the director of the FBI in a fit of pique. Likewise, repealing Obamacare collapsed partly because he lacked the knowledge and charisma to win over rebel Republicans. He reacted to that setback by belittling the leader of the Senate Republicans, whose help he needs to pass legislation. So much for getting things done.
Mr Trump’s inept politics stem from a moral failure. Some counter-demonstrators were indeed violent, and Mr Trump could have included harsh words against them somewhere in his remarks. But to equate the protest and the counter-protest reveals his shallowness. Video footage shows marchers carrying fascist banners, waving torches, brandishing sticks and shields, chanting “Jews will not replace us”. Footage of the counter-demonstration mostly shows average citizens shouting down their opponents. And they were right to do so: white supremacists and neo-Nazis yearn for a society based on race, which America fought a world war to prevent. Mr Trump’s seemingly heartfelt defence of those marching to defend Confederate statues spoke to the degree to which white grievance and angry, sour nostalgia is part of his world view.
At the root of it all is Mr Trump’s temperament. In difficult times a president has a duty to unite the nation. Mr Trump tried in Monday’s press conference, but could not sustain the effort for even 24 hours because he cannot get beyond himself. A president needs to rise above the point-scoring and to act in the national interest. Mr Trump cannot see beyond the latest slight. Instead of grasping that his job is to honour the office he inherited, Mr Trump is bothered only about honouring himself and taking credit for his supposed achievements.
Presidents have come in many forms and still commanded the office. Ronald Reagan had a moral compass and the self-knowledge to delegate political tactics. LBJ was a difficult man but had the skill to accomplish much that was good. Mr Trump has neither skill nor self-knowledge, and this week showed that he does not have the character to change.
This is a dangerous moment. America is cleft in two. After threatening nuclear war with North Korea, musing about invading Venezuela and equivocating over Charlottesville, Mr Trump still has the support of four-fifths of Republican voters. Such popularity makes it all the harder for the country to unite.
This leads to the question of how Republicans in public life should treat Mr Trump. Those in the administration face a hard choice. Some will feel tempted to resign. But his advisers, particularly the three generals sitting at the top of the Pentagon, the National Security Council and as Mr Trump’s chief of staff, are better placed than anyone to curb the worst instincts of their commander-in-chief.
For Republicans in Congress the choice should be clearer. Many held their noses and backed Mr Trump because they thought he would advance their agenda. That deal has not paid off. Mr Trump is not a Republican, but the solo star of his own drama. By tying their fate to his, they are harming their country and their party. His boorish attempts at plain speaking serve only to poison national life. Any gains from economic reform—and the booming stockmarket and low unemployment owe more to the global economy, tech firms and dollar weakness than to him—will come at an unacceptable price.
Republicans can curb Mr Trump if they choose to. Rather than indulging his outrages in the hope that something good will come of it, they must condemn them. The best of them did so this week. Others should follow.
Donald Trump satisfies every criteria for narcissistic personality disorder.
NARCISSISTIC PERSONALITY DISORDER
From Wikipedia, the free encyclopedia
This article is about the psychiatric condition. For information about the trait, see Narcissism. Synonyms -see megalomania
Symptoms: Exaggerated feelings of self-importance, excessivea need for admiration, lack of understanding of others’ feelings
Usual Onset: Young adulthood
Duration: Long Term
Cause: Unknown
Treatment: Difficult
Frequency: 1%
Narcissistic personality disorder (NPD) is a personality disorder in which there is a long-term pattern of abnormal behaviour characterized by exaggerated feelings of self-importance, an excessive need for admiration, and a lack of understanding of others’ feelings. People affected by it often spend a lot of time thinking about achieving power or success, or about their appearance. They often take advantage of the people around them The behaviour typically begins by early adulthood, and occurs across a variety of situations.
The cause of narcissistic personality disorder is unknown. It is a personality disorder classified within cluster B by the Diagnostic and Statistical Manual of Mental Disorders. Diagnosis is by a healthcare professional interviewing the person in question The condition needs to be differentiated from mania and substance use disorder.
Treatments have not been well studied. Therapy is often difficult as people with the disorder frequently do not consider themselves to have a problem. About one percent of people are believed to be affected at some point in their life. It appears to occur more often in males than females and affects young people more than older people. The personality was first described in 1925 by Robert Waelder while the current name for the condition came into use in 1968.
SIGNS & SYMPTOMS
Persons with narcissistic personality disorder (NPD) are characterized by their persistent grandiosity, excessive need for admiration, and a personal disdain for, and lack of empathy for other people. As such, the person with NPD usually displays the behaviours of arrogance, a sense of superiority, and actively seeks to establish abusive power and control over other people. Narcissistic personality disorder is a condition different from self-confidence (a strong sense of self); people with NPD typically value themselves over other persons to the extent that they openly disregard the feelings and wishes of others, and expect to be treated as superior, regardless of their actual status or achievements. Moreover, the person with narcissistic personality disorder usually exhibits a fragile ego (Self-concept), an inability to tolerate criticism, and a tendency to belittle others in order to validate their own superiority.
The DSM-5 indicates that persons with NPD usually display some or all of the following symptoms, typically without the commensurate qualities or accomplishments:
• Grandiosity with expectations of superior treatment from other people
• Fixated on fantasies of power, success, intelligence, attractiveness, etc.
• Self-perception of being unique, superior, and associated with high-status people and institutions
• Needing continual admiration from others
• Sense of entitlement to special treatment and to obedience from others
• Exploitative of others to achieve personal gain
• Unwilling to empathize with the feelings, wishes, and needs of other people
• Intensely envious of others, and the belief that others are equally envious of them
• Pompous and arrogant demeanor
Narcissistic personality disorder usually develops in adolescence or during early adulthood. It is not uncommon for children and adolescents to display some traits similar to those of NPD, but such occurrences usually are transient, and do not meet the criteria for a diagnosis of NPD. True symptoms of NPD are pervasive, apparent in varied situations, and rigid, remaining consistent over time. The NPD symptoms must be sufficiently severe to the degree that significantly impairs the person’s capabilities to develop meaningful human relationships. Generally, the symptoms of NPD also impair the person’s psychological abilities to function, either at work, or school, or important social settings. The DSM-5 indicates that the traits manifested by the person must substantially differ from cultural norms, in order to qualify as symptoms of NPD.
ASSOCIATED FEATURES
People with NPD tend to exaggerate their skills and accomplishments as well as their level of intimacy with people they consider to be high-status. Their sense of superiority may cause them to monopolize conversations, and to become impatient or disdainful when others talk about themselves. In the course of a conversation, they may purposefully or unknowingly disparage or devalue the other person by overemphasizing their own success. When they are aware that their statements have hurt someone else, they tend to react with contempt and to view it as a sign of weakness. When their own ego is wounded by a real or perceived criticism, their anger can be disproportionate to the situation, but typically, their actions and responses are deliberate and calculated. Despite occasional flare-ups of insecurity, their self-image is primarily stable (i.e., overinflated).
To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others’ needs and the effects of their behaviour on others, and insist that others see them as they wish to be seen. Narcissistic individuals use various strategies to protect the self at the expense of others. They tend to devalue, derogate, insult and blame others, and they often respond to threatening feedback with anger and hostility. Since the fragile ego of individuals with NPD is hypersensitive to perceived criticism or defeat, they are prone to feelings of shame, humiliation and worthlessness over minor or even imagined incidents. They usually mask these feelings from others with feigned humility or by isolating themselves socially, or they may react with outbursts of rage, defiance, or by seeking revenge. The merging of the “inflated self-concept” and the “actual self” is seen in the inherent grandiosity of narcissistic personality disorder. Also inherent in this process are the defence mechanisms of denial, idealization and devaluation.
According to the DSM-5, “Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute narcissistic personality disorder.” Due to the high-functionality associated with narcissism, some people may not view it as an impairment in their lives. Although overconfidence tends to make individuals with NPD ambitious, it does not necessarily lead to success and high achievement professionally. These individuals may be unwilling to compete or may refuse to take any risks in order to avoid appearing like a failure. In addition, their inability to tolerate setbacks, disagreements or criticism, along with lack of empathy, make it difficult for such individuals to work cooperatively with others or to maintain long-term professional relationships with superiors and colleagues.
CAUSES
The causes of narcissistic personality disorder are unknown. Experts tend to apply a biopsychosocial model of causation, meaning that a combination of environmental, social, genetic and neurobiological factors are likely to play a role in formulating a narcissistic personality.
Genetic. There is evidence that narcissistic personality disorder is heritable, and individuals are much more likely to develop NPD if they have a family history of the disorder. Studies on the occurrence of personality disorders in twins determined that there is a moderate to high for narcissistic personality disorder.
However the specific genes and gene interactions that contribute to its cause, and how they may influence the developmental and physiological processes underlying this condition, have yet to be determined.
Environment. Environmental and social factors are also thought to have a significant influence on the onset of NPD. In some people, pathological narcissism may develop from an impaired attachment to their primary caregivers, usually their parents. This can result in the child’s perception of himself/herself as unimportant and unconnected to others. The child typically comes to believe they have some personality defect that makes them unvalued and unwanted. Overindulgent, permissive parenting as well as insensitive, over-controlling parenting, are believed to be contributing factors.
According to Leonard Groopman and Arnold Cooper, the following factors have been identified by various researchers as possible factors that promote the development of NPD:
• An oversensitive temperament (personality traits) at birth.
• Excessive admiration that is never balanced with realistic feedback.
• Excessive praise for good behaviours or excessive criticism for bad behaviours in childhood.
• Overindulgence and overvaluation by parents, other family members, or peers.
• Being praised for perceived exceptional looks or abilities by adults.
• Severe emotional abuse in childhood.
• Unpredictable or unreliable caregiving from parents.
• Learning manipulative behaviours from parents or peers.
• Valued by parents as a means to regulate their own self-esteem.
•Cultural elements are believed to influence the prevalence of NPD as well since NPD traits have been found to be more common in modern societies than in traditional ones.
Pathophysiology. There is little research into the neurological underpinnings of narcissistic personality disorder. However, recent research has identified a structural abnormality in the brains of those with narcissistic personality disorder, specifically noting less volume of gray matter in the left anterior insula. Another study has associated the condition with reduced gray matter in the prefrontal cortex.
The brain regions identified in the above studies are associated with empathy, compassion, emotional regulation, and cognitive functioning. These findings suggest that narcissistic personality disorder is related to a compromised capacity for emotional empathy and emotional regulation.
DIAGNOSIS
DSM-5. The formulation of narcissistic personality disorder in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) was criticised for failing to describe the range and complexity of the disorder. Critics said it focuses overly on “the narcissistic individual’s external, symptomatic, or social interpersonal patterns—at the expense of … internal complexity and individual suffering,” which they argued reduced its clinical utility.
The Personality and Personality Disorders Work Group originally proposed the elimination of NPD as a distinct disorder in DSM-5 as part of a major revamping of the diagnostic criteria for personality disorders, replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains. Some clinicians objected to this, characterizing the new diagnostic system as an “unwieldy conglomeration of disparate models that cannot happily coexist” and may have limited usefulness in clinical practice. The general move towards a dimensional (personality trait-based) view of the Personality Disorders has been maintained despite the reintroduction of NPD.
ICD-10. The World Health Organization’s (WHO) International Statistical Classification of Diseases and Related Health Problems, 10th Edition(ICD-10) lists narcissistic personality disorder under Other specific personality disorders. It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Subtypes. While the DSM-5 regards narcissistic personality disorder as a homogeneous syndrome, there is evidence for variations in its expression. In a 2015 paper, two major presentations of narcissism are typically suggested, an “overt” or “grandiose” subtype, characterized by grandiosity, arrogance, and boldness, and a “covert” or “vulnerable” subtype characterized by defensiveness and hypersensitivity. Those with “narcissistic grandiosity” express behaviour “through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism.”Psychiatrist Glen Gabbard described the subtype, which he referred to as the “oblivious” subtype as being grandiose, arrogant, and thick-skinned. The subtype of “narcissistic vulnerability” entails (on a conscious level) “helplessness, emptiness, low self-esteem, and shame, which can be expressed in the behaviour as being socially avoidant in situations where their self-presentation is not possible so they withdraw, or the approval they need/expect is not being met.” Gabbard described this subtype, which he referred to as the “hypervigilant” subtype as being easily hurt, oversensitive, and ashamed. In addition, a “high-functioning” presentation, where there is less impairment in the areas of life where those with a more severe expression of the disorder typically have difficulties in, is suggested.
SUBTYPES. Theodore Millon suggested five subtypes of narcissism. However, there are few pure variants of any subtype, and the subtypes are not recognized in the DSM or ICD.
Unprincipled narcissist. Including antisocial features – Deficient conscience; unscrupulous, amoral, disloyal, fraudulent, deceptive, arrogant, exploitive; a con artist and charlatan; dominating, contemptuous, vindictive.
Amorous narcissist. Including histrionic features. Sexually seductive, enticing, beguiling, tantalizing; glib and clever; disinclined to real intimacy; indulges hedonistic desires; bewitches and inveigles others; pathological lying and swindling. Tends to have many affairs, often with exotic partners.
Compensatory narcissist. Including negativistic and avoidant features. Seeks to counteract or cancel out deep feelings of inferiority and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, noteworthy; self-worth results from self-enhancement.
Elitist narcissist. Variant of pure pattern. Feels privileged and empowered by virtue of special childhood status and pseudo-achievements; entitled façade bears little relation to reality; seeks favoured and good life; is upwardly mobile; cultivates special status and advantages by association.
Normal narcissist. Absent of the traits of the other four. Least severe and most interpersonally concerned and empathetic, still entitled and deficient in reciprocity; bold in environments, self-confident, competitive, seeks high targets, feels unique; talent in leadership positions; expecting of recognition from others.
COMORBITITY. NPD has a high rate of comorbidity with other mental disorders. Individuals with NPD are prone to bouts of depression, often meeting criteria for co-occurring depressive disorders. In addition, NPD is associated with bipolar disorder, anorexia, and substance use disorders, especially cocaine. As far as other personality disorders, NPD may be associated with histrionic, borderline, antisocial, and paranoid personality disorders.
TREATMENT
Narcissistic personality disorder is rarely the primary reason for people seeking mental health treatment. When people with NPD enter treatment, it is typically prompted by life difficulties or to seek relief from another disorder, such as major depressive disorder, substance use disorders, bipolar disorder, or eating disorders, or at the insistence of relatives and friends. This is partly because individuals with NPD generally have poor insight and fail to recognize their perception and behaviour as inappropriate and problematic due to their very positive self-image.
Treatment for NPD is centred around psychotherapy. In the 1960s, Heinz Kohut and Otto Kernberg challenged the conventional wisdom of the time by outlining clinical strategies for using psychoanalytic psychotherapy with clients with NPD that they claimed were effective in treating the disorder. Contemporary treatment modalities commonly involve transference-focused, metacognitive, and schema-focused therapies. Some improvement might be observed through the treatment of symptoms related to comorbid disorders with psychopharmaceuticals, but as of 2016, according to Elsa Ronningstam, psychologist at Harvard Medical School, “Alliance building and engaging the patient’s sense of agency and reflective ability are essential for change in pathological narcissism.”
Pattern change strategies performed over a long period of time are used to increase the ability of those with NPD to become more empathic in everyday relationships. To help modify their sense of entitlement and self-centredness schema, the strategy is to help them identify how to utilize their unique talents and to help others for reasons other than their own personal gain. This is not so much to change their self-perception of their “entitlement” feeling but more to help them empathize with others. Another type of treatment would be temperament change. Psychoanalytic psychotherapy may be effective in treating NPD, but therapists must recognize the patient’s traits and use caution in tearing down narcissistic defences too quickly. Anger, rage, impulsivity, and impatience can be worked on with skill training. Therapy may not be effective because patients may receive feedback poorly and defensively. Anxiety disorders and somatoform dysfunctions are prevalent but the most common would be depression.
Group treatment has its benefits as the effectiveness of receiving peer feedback rather than the clinician’s may be more accepted, but group therapy can also contradict itself as the patient may show “demandingness, egocentrism, social isolation and withdrawal, and socially deviant behaviour”. Researchers originally thought group therapy among patients with NPD would fail because it was believed that group therapy required empathy that NPD patients lack. However, studies show group therapy does hold value for patients with NPD because it lets them explore boundaries, develop trust, increase self-awareness, and accept feedback. Relationship therapy stresses the importance of learning and applying four basic interpersonal skills: “…effective expression, empathy, discussion and problem solving/conflict resolution”.Marital/relationship therapy is most beneficial when both partners participate.
No medications are indicated for treating NPD, but may be used to treat co-occurring mental conditions or symptoms that may be associated with it such as depression, anxiety, and impulsiveness if present.
PROGNOSIS.The effectiveness of psychotherapeutic and pharmacological interventions in the treatment of narcissistic personality disorder has yet to be systematically and empirically investigated. Clinical practice guidelines for the disorder have not yet been created, and current treatment recommendations are largely based on theoretical psychodynamic models of NPD and the experiences of clinicians with afflicted individuals in clinical settings.
The presence of NPD in patients undergoing psychotherapy for the treatment of other mental disorders is associated with slower treatment progress and higher dropout rates.
EPIDEMIOLOGY. Lifetime prevalence of NPD is estimated at 1% in the general population and 2% to 16% in clinical populations. A 2010 systematic review found the prevalence of NPD to be between 0% to 6% in community samples. There is a small gender difference, with men having a slightly higher incidence than in women.
According to a 2015 meta-analysis that looked at gender differences in NPD, there has recently been a debate about a perceived increase in the prevalence of NPD among younger generations and among women. However, the authors found that this was not reflected in the data and that the prevalence has remained relatively stable for both genders over the last 30 years (when data on the disorder were first collected).
HISTORY.The use of the term “narcissism” to describe excessive vanity and self-centredness predates by many years the modern medical classification of narcissistic personality disorder. The condition was named after Narcissus, a mythological Greek youth who became infatuated with his own reflection in a lake. He did not realize at first that it was his own reflection, but when he did, he died out of grief for having fallen in love with someone that did not exist outside himself.
In popular culture, narcissistic personality disorder has been called megalomania.
FICTION.In the film To Die For, Nicole Kidman’s character wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she “was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder… had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder”.
Other examples in popular fiction include television characters Adam Demamp (portrayed by Adam DeVine in Workaholics) and Dennis Reynolds (portrayed by Glenn Howerton in It’s Always Sunny in Philadelphia).
