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Book Reviews |
The debate over narcissistic personality disorder has been waged now for more than two decades. On the one side have stood the supporters of an evolutionary doctrine deriving from the school of object relations, as led by Otto Kernberg; on the other side, the supporters of a revolutionary doctrine deriving from the concepts of selfobject as led by the late Heinz Kohut. In the past there has been little commonality between the two. Disorders of Narcissism seeks to begin the bridge this gap by presenting what is currently known about the subject from the most highly regarded theorists and clinicians in the field. If the understanding of narcissistic personality disorder is a work in progress, then Ronningstam's textbook is the most current and meaningful guide to this work.
The 24 contributors, luminaries all, include Drs. Kernberg, Cooper, Gabbard, Ornstein, Nemiah, and Maltsberger, to name but a few. Each author contributes a chapter to one of the four sections: Diagnostic and Theoretical Considerations, Treatment Implications, Special Clinical Considerations, and Research. Dr. Ronningstam writes an overall introduction to the work, provides cogent and helpful introductions to each section, and adds an afterword. Perhaps her main achievement, however, was in persuading all of these gifted and knowledgeable individuals to make their contributions in the first place.
One of the helpful clinical chapters that stands out is Dr. Maltsberger's "Pathological Narcissism and Self-Regulatory Processes in Suicidal States," which appears in the Special Clinical Considerations section. He focuses on how we can come to understand the mechanisms by which individuals with narcissistic personality disorder (NPD) can kill themselves. He begins by noting earlier work on NPD and its relationship to aggressive, self-destructive behaviors, especially the description of Kernberg's "malignant narcissism." Following Hartmann and Stolorow's lead, he then defines terms concerning disarticulation of self-representations and normal and disturbed self-regulation. Next, he enlarges on two themes first found in Klein: the "metamorphic suicide" and the "execution suicide." Here he reworks some of Klein's ideas regarding "bad" internal objects into a more useful form. In the metamorphic type of suicide, unacceptable parts of the self are conceptualized as being able to be left behind in a cast-off and evil chrysalis while the purer and more beautiful butterfly is able to ascend above. In the execution type, the bad parts of the self—often the physical—are separated out and objectified. This then makes it possible for the remainder to rid itself of these unwanted portions through death, with the final sense of having obtained mastery. The chapter is enriched by the use of telling clinical material, including reports of patients' dreams that are illustrative of and appropriate to the above points.
Although containing less clinical material, the more theoretical chapters in the early part of the book—especially the chapters by Stone, Kernberg, and Ornstein—are equally well written and easily digestible, even if one is not, by study or inheritance, a "selfobjectivist."
The only criticism that can be offered is general, not specific to this work: it involves the disadvantages of an edited book versus a book written by one author. Every book ever written tells a story. One author can usually tell the story with a simplicity and unity of idea and style that even the most dedicated editor can never hope to achieve. Of course some subjects—and narcissistic personality disorder may by its nature be chief among them—do not well lend themselves to such unity of view, or at least not to date. Ronningstam's good efforts, however, lead one to believe that as the field develops further, that day may not be so far off.
As to the technical side of this work, the text is legible and the charts, graphs, and illustrations are relevant and easily comprehensible. Some of the chapters present interesting clinical material in the form of case vignettes. The references and bibliography are reasonable and current.
This book is obligatory for those who treat in this field and would be a welcome edition to the libraries of those with a more general practice. Even though much yet remains to be done in the domain of NPD, this book is the current "gold standard" for this diagnosis. Disorders of Narcissism is therefore highly recommended.
Footnotes
Dr. Sovine is in private practice in Milwaukee and is Clinical Assistant Professor of Psychiatry at the Medical College of Wisconsin. His first work of fiction, the psychopolitical thriller Magnolia Reich: An American Holocaust, appeared in August.
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