Yecheskel Cohen, Ph.D.
ABSTRACT
I draw a distinction between two clinical pictures in children, borderline and narcissistic disorders. Both belong to the realm of personality disorder—or, perhaps, disorders in the development of the personality—but only the former has been widely reviewed and thoroughly investigated in the professional literature. I raise the question how and when these disorders emerge, stressing that both derive from the early, preoedipal period, and precede completion of the separation-individuationprocesses. Both disorders reveal manifestations of grandiosity which I view as a defense against the two underlying emotional experiences of the disorders: the experience of feeling alone in the borderline case, and the experience of "worthlessness" in the narcissistic personality.IN THIS STUDY I SHALL DEAL WITH TWO SEVERE DISORDERS USUALLY included under the rubric of personality disorders in children, i.e., narcissistic disorder and borderline disorder. An attempt will be made to elucidate one specific phenomenon—grandiosity—which usually appears as a defense against central problems characterizing these disturbances.
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Director of B'nai B'rith Women Children's Home, Israel; supervising and training analyst, Israel Psychoanalytic Institute; faculty member, the Hebrew University of Jerusalem, Department of Psychology.
I would like to thank Joseph Sandler for his kind criticism, and Noa Haas and Irit Ben-Ezer for their help in the preparation of this paper.
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REVIEW OF THE LITERATURE
The professional literature on borderline disorders in children is extensive and far-ranging; that relating to narcissistic disorders in children, on the other hand, is very limited. Bleiberg (1988) attempted to shed light on this discrepancy on the basis of a lack of consensus on the definition of narcissistic disorders in children and the scarcity of material which can explain the developmental components of such disorders in children.A few authors have attributed the paucity of data on narcissistic disorders in children to the phenomenon of normal narcissism in children. Otto Kernberg(1975) compares normal and pathological narcissism in children, as do Egan and Paulina Kernberg (1984), who conclude, however, that narcissistic personality disorder can be diagnosed in children on the basis of the same characteristics of this disorder in adults.
According to Bleiberg (1984), the narcissistic personality exhibits the following traits: defective interpersonal relations, coldness, exploitativeness, manipulativeness, the need to control others; impulsivity and a low frustration tolerance; learning problems; rapid mood changes and lability in self-esteem; lying, stealing, and frequent lawbreaking; exhibitionism, overbearing behavior, arrogance, and repeated manifestations of the need for admiration and attention; strong expressions of jealousy.
Colarusso (1984) finds that borderline children exhibit multiple defects in ego functioning, in particular perception, motor development, adaptation to reality, and organization of thought and language; a frequent sense of helplessness; failure to differentiate between self and object; preoedipalfixation, culminating in failure to reach the oedipal stage and to integrate sexuality with the otherpersonality components; overwhelming anxiety, in particular the fear of annihilation and fragmentation leading to uncontrollable outbursts; relatively unimpaired reality testing.
Otto Kernberg(1984) criticizes diagnosis on the basis of symptoms, advocating instead an approach utilizing a structural analysis of the personality. He examines the personality in terms of the quality of the formation of self, mechanisms of defense, and the extent of reality testing. Kernberg views these two disorders as indications of severe damage in the formation of self identity, and concludes that the two in fact represent one type of emotional disorder. They cannot be placed on a continuum, and they do not differ from each other structurally.
A few attempts have been made to distinguish between narcissistic
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and borderline disorders in children. Both Rinsley and Adler view the two disorders as part of a continuum:
In both borderline and narcissistic cases, the ever-present threat of abandonment underlines all else. In the case of the borderline personality, the threat concerns overall growth apart from the symbiotic mother; in the case of the narcissistic personality, the threat concerns achievement and relationships apart from her [Rinsley, 1988, p. 393].
Whereas the narcissistic patient uses the selfobject to maintain his tenuous sense of self-worth, the borderline patient uses it primarily to provide forms of holding-soothing security, without which he inevitably undergoes a regression through the various stages of loss of self-cohesiveness, culminating in the ultimate threat of self-disintegration… The greater loss of self-cohesiveness in regressed borderline patients can be attributed to the fact that failure in the holding-soothing line is developmentally prior to failure in the self-worth line [Adler, 1985, p. 89].
Adler (1985) makes a distinction very relevant to the subject of this study. He claims that the self of the borderline personality is less formed than that of the narcissistic patient and is frequently exposed to the feeling of being threatened by annihilation and total destruction. Adler therefore underscores the central emotion of the borderline personality as a sense of being alone and therefore prone to this threat. In contrast, the self of the narcissistic personality is somewhat more developed; he is not threatened with annihilation, and his central emotion is lack of self-esteem. In other words, the borderline personality feels alone, while the narcissistic one feels worthless.
Analyzing narcissistic disorder in children, Bene (1979) states that both instances involve a pathology of the self, but narcissistic children are capable of more unimpaired reality testing than borderline children; they also have a better command of secondary processes, i.e., abstraction and logic. However, Bene distinguishes between the two according to the quality and nature of their object relations, and in this sense her distinction is very similar to Adler's. Bene argues that the borderline personality tends to merge with the object, while the narcissistic personality tends to view the object as complementary to his self. Hence, as in Adler's view, the borderline personality's desire to merge can be seen to derive from his feeling of being alone, whereas the narcissist's desire for completion can be viewed as the result of his inner feeling of worthlessness. In both cases the fears and anxieties are inherent in the fulfillment of these desires: implicit in the desire to merge is the fear of the annihilation which informs the act of merging;
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and implicit in the fulfillment of the wish for completion is the admission of the necessity of the object for the value of the self.
Fast and Chethik (1972) explain borderline disorder in children as first and foremost expressing impaired object relations. The self and the object representations are not integrated, which may result in merging of the self and object. The various types of such merging may indicate a severe inability to differentiate or clearer differentiations in which the child seeks greater identity between self and object and ignores signs of difference between them.
Gabbard (1989) claims that two types of narcissistic disorder can be distinguished: "oblivious" and "hypervigilant" narcissism. In oblivious narcissism the object is ignored: the child is oblivious to the object's reactions, preoccupied with himself, arrogant and aggressive. He constantly needs to be the focus of attention and is not responsive or sensitive to the object's vulnerability. Hypervigilant narcissism expresses itself in hypersensitivity to the object and its reactions. The child avoids being the focus of attention and is excessively vulnerable and sensitive to criticism. In the former instance the child is occupied with cultivating and grooming himself while ignoring his surroundings, and in the latter instance the child is occupied with grooming his relations with the object and its meaning for himself. This distinction is somewhat reminiscent of the distinction between narcissistic and borderline personalities according to whether the central emotion is worthlessness or helplessness: someone who feels helpless will be more dependent on the object, whereas someone who feels worthless will be more dependent on the self.
In view of the great confusion between these two disorders, further distinctions and subcategories serve only to complicate the matter. Kernberg's method, which has been followed by Rinsley and others, is far more practical and clinical. Rinsley (1980) sums it up:
In accordance with the view of narcissistic personality as a subtype of borderline personality, it may be postulated that the basic, pathogenic, doubly binding pattern of mother-infant interaction that is etiologic for borderline personality is likewise etiologic for narcissistic personality. Clinical experience indeed bears this out. In narcissistic cases, however, the mother rewards, or provides reinforcement and approval for the child's growth toward separation-individuation, but only and ultimately in relation to herself, thereby fixating the developing child's infantile grandiosity in relation to achievements which center upon the still partly fused self and object images [p. 131].
In the narcissistic personality disorder the child is threatened by what he "reads" as the requirement to fulfill a certain role imposed on
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him by his mother, whereas in the borderline case the threat is that of abandonment. Separation and individuation in the borderline personality lead to the child's abandonment by the mother, in the sense of his being alone and helpless. In the narcissistic personality, separation and individuation are possible only at the price of relinquishing self-worth. Thus the literature attributes to the narcissistic personality a better ability to differentiate between self and object and a better hold on object constancy.
The lack of clarity regarding the distinction between the two types of disorders and the possibility of viewing them as subgroups of a single disorder replicates the controversy on the question of onset of the disorders from the developmental point of view. Most authors posit an earlier onset for borderline disorder because the narcissistic personality seems more developed in terms of differentiating between self and object as well as in ego functioning and reality testing.
GRANDIOSITY
By describing and explicating the mechanism of grandiosity, I would like to attempt to elucidate what is common to these two disorders and how they differ from each other. Because it does not appear to contribute anything to this discussion, I shall not discuss the controversy regarding onset. I shall also disregard here the controversy as to whether grandiosity is a fixation, as Masterson (1975) believes, or whether it is a clear defense mechanism, as Kernberg and others claim. I believe that the phenomenon of grandiosity can be discerned in narcissistic and borderline personality disorders. It is central to both, although it exhibits different characteristics in each disorder. An examination of these characteristics will better enable us to focus on the differences between the two disorders and to clarify the different etiologies.From the clinical experience with children with narcissistic and borderline disorders, two discrete kinds of grandiosity can be discerned. These two kinds can be distinguished from each other according to the following characteristics: (1) direction and content; (2) the underlying emotional experience; (3) splitting as a precondition; and (4) differentiation between self and object (distinguishing boundaries).
DIRECTION AND CONTENT
We can distinguish between two directions of grandiosity and hence two areas of content. In some cases grandiosity is directed toward the various objects, real or imaginary, in the immediate or less immediateWARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever.
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environment. These are expressions concerning control over and destruction of—or, at times, salvation of—the object. The child attributes to himself characteristics of strength which enable him to do whatever he wants to the object. What is noticeable here is the extent to which grandiosity is based on the physical power and, in this sense, there is not much variety. However, grandiosity is always directed at an object or objects. A distinct sense of omnipotence in the narrow meaning of the word, i.e., in the field of physical power, strength, and violence, is obvious. An example of this kind of grandiosity can be found in the words of 8-year-old R. Talking about himself, he says:
When I was, like, two I was at the Zikaron kindergarten. I, like, stayed with my father when I was four, like, and my father was picked up, they thought he stole ten guns. So they took him to jail for two years and twenty days. I was left on my own. So I went to someone, some policeman … a good friend of mine. I've known him since I was really, like, small, I really knew him well. I told him to let my father go. 'Cause he was the captain there, the biggest. I told him to release my father. He said alright and then he let my father go. If anything happens to me, he comes right away. Everyone likes me. They always like me. You like me too, right?
In other cases, grandiosity is clearly directed at a different target: the self. In these instances the child sees primarily himself and attributes to himself superior traits in various, not necessarily physical, areas. The child may feel an exaggerated sense of self-worth in his mental prowess, or his knowledge, his cunning, wealth, property, skills, achievements, and so forth; the object exists almost incidentally, an anonymous audience devoid of any unique value of its own, perhaps no more than a counterweight against which the child can even more intensely be aware of his own self-worth.
For example, 8-year-old H. literally burst into the room for his session and, oblivious to the therapist's presence, barked out a few commands, such as indicating that he wanted the ball. Although the orders were directed at the therapist, it was obvious that H. was addressing himself or the space around him, giving the therapist the feeling that she did not exist. H. told the therapist to stand in a specific spot in the room and began a game of shooting baskets. After several throws, H. took a few dolls and sat them on the table, calling them the spectators for the game. After each shot he clapped hands and alternately shouted and muttered to himself. When the therapist made a basket, H. argued that she had shot from the wrong spot and therefore did not get any points. He added his own points to his score from the previous therapy session, but counted only what the therapist shot during this session. Every once in a while he imitated the voice of the TV announcer
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getting excited and even tried to project an adult's voice. In the course of the session a small leak was discovered in the ceiling. H. muttered to himself that he would take care of the problem right away. He took a rag, some nails, and a hammer and, without any explanation, put a chair on the table, got up on it, and tried to nail the rag onto the ceiling in order to stop the leak. When he could not do so, H. left the things behind and decided to start a new game; it became very close, and he invented different rules, inviting the dolls, i.e., the spectators, to watch him beat the therapist.
In both cases the opposite axis is, to a certain degree, related to: while predominantly concerned with the object, a relation to the self exists in the first case; just as in the second case, predominantly concerned with the self, we can also perceive a relation to the object. What I wish to stress here is the direction of the major investment in grandiosity in the sense of instinctual aim.