Letter to Editor

dividing the number needed to treat (NNT) for the prevention of depressive episodes by the NNT for the prevention of manic episodes. Drugs with a PI superior to one have stronger anti-manic versus anti-depressant prophylactic properties, whereas those with PI inferior to one are more effective for preventing depressive episodes than the manic ones. Drugs with the PI of one may have a comparable anti-manic and anti-depressive potential.[1] A few examples of pharmacological agents with calculated PI include 12.09 for risperidone, 1.39 for lithium, 1.14 for quetiapine, and 0.40 for lamotrigine. [1] Similarly, PI for psychological interventions include 0.33-0.89 for cognitive-behavioral therapy and 0.73-0.78 for psychoeducation.[2] The clinical utility of PI has been a matter of intense debate in the recent times. A recent study on a large sample of bipolar patients demonstrated the usefulness of PI in clinical decision-making. The study demonstrated that the treatment of patients with mania predominant polarity was oriented mostly toward mania prevention, as evidenced by higher PI, while treatment of depression predominant polarity patients was characterized by lower mean PI and hence directed toward preventing depression.[3] The ultimate motive of incorporating evidence-based medicine to clinical practice in psychiatry has also been lauded by several clinicians and researchers. However, there are multiple arguments against usefulness of PI as a bipolar metric in clinical practice. Most importantly, summarizing the therapeutic response to medication for a complex heterogeneous entity like bipolar disorder can be potentially misleading. Furthermore, combining results of different trials in calculation of PI is likely to result in oversimplification. Multiple factors, including the polarity of the index episode, number of previous episodes, time since last episode, baseline severity of mood symptoms, dropout rates, treatment adherence characteristics and duration of prospective follow-up may influence the results of different trials and hence not accounting for the above confounders can result

in poor validity in calculation of PI.[4] Hence, many authors are skeptical about the clinical utility of PI though it could be a potentially valuable construct. Future research is likely to provide more insight into this interesting debate and it need not be again emphasized that developing novel metrics that would aid psychiatric clinicians in their decision-making process is a step in the right direction.

Sundar Gnanavel Department of Psychiatry, AIIMS, New Delhi, India Address for correspondence: Dr. Sundar Gnanavel, Department of Psychiatry, AIIMS, Ansari Nagar, New Delhi - 110 029, India. E-mail: [email protected]

REFERENCES 1.

Popovic D, Reinares M, Goikolea JM, Bonnin CM, GonzalezPinto A, Vieta E. Polarity index of pharmacological agents used for maintenance treatment of bipolar disorder. Eur Neuropsychopharmacol 2012;22:339-46. 2. Popovic D, Reinares M, Scott J, Nivoli A, Murru A, Pacchiarotti I, et al. Polarity index of psychological interventions in maintenance treatment of bipolar disorder. Psychother Psychosom 2013;82:292-8. 3. Popovic D, Torrent C, Goikolea JM, Cruz N, SánchezMoreno J, González-Pinto A, et al. Clinical implications of predominant polarity and the polarity index in bipolar disorder: A naturalistic study. Acta Psychiatr Scand 2014;129:366-74. 4. Alphs L, Berwaerts J, Turkoz I. Limited utility of number needed to treat and the polarity index for bipolar disorder to characterize treatment response. Eur Neuropsychopharmacol 2013;23:1597-9. Access this article online Quick Response Code Website: www.ijpm.info

DOI: 10.4103/0253-7176.155682

Beauvoir and Demystifying Paradoxical Characteristics of Narcissistic Personality Disorder Sir, In an earlier letter;[1] I examined some paradoxical Indian Journal of Psychological Medicine | Apr - Jun 2015 | Vol 37 | Issue 2

characteristics of narcissistic personality disorder (NPD). In this letter, I will further elucidate the findings in this previous work by infusing an interpretation of Simone 251

Letter to Editor

de Beauvoir’s philosophy[2] by Bauer (2001).[3] This letter is significant because it provides an ontological grounding to understand narcissistic behavior. I will argue that narcissistic behavior can be explained through the narcissist desire to be recognized by another consciousness as “in-itself for-itself,” as, in other words, an object with freedom. The reason for this desire to be objectified as a subject is that it provides the recognition of an established identity or self which the narcissistic lacks. As a result, the archaic self-object needs (desires) that (Kohut, 1971)[4] argued narcissists require, can be explained as providing a feeling of grounding, stability and a fixed place in the world from the recognition of their subjectivity by another consciousness. This is important to a narcissist as it can prevent anxiety arising from an awareness of the free subjectivity of others, which results in an ambiguous dialectical struggle for recognition with others during life. The problem with this behavior is that it denies the reality of subjectivity and freedom of another consciousness which will result in inadequate and illusory expectations from interpersonal relationships, sustaining the vicious circle of narcissism through inadequate satisfaction of self-object needs. These narcissistic “Deadly Habits” attempt to demolish the freedom of another subject and therefore destroys interpersonal relationships, as freedom has been identified as one of the basic human needs. If mutual recognition of the subject/object duality of the narcissist’s own consciousness and that of another consciousness is not achieved, this cycle of severed interpersonal relationships and self-destructive behavior can be expected to repeat. In demystifying paradoxical characteristics of NPD, using Kohut’s theory of narcissism, I explained “By not receiving necessary self-object transferences through decisive epochs in development, the young individual cannot build the competence to control self-respect or construct a positive self-image.[5] Consequently, the child, now an adult, depends on other humans to construct their self-image. The self-object transferences received as an adult provide a feeling of significance, which was not established during child development.[5] However, NPD persons are apprehensive of meeting self-object absence as an adult. In order to feel the control of their fate, NPD persons present a mindset of dominance in the interpersonal sphere. As a result of this authoritarian manner, persons with NPD typically have a record of numerous unsuccessful relationships”.[6] I argued that the unsuccessful relationships encountered in narcissism occurs due to paradoxical behavioral characteristics where instead of behaving in a way to increase the chance of receiving self-object transferences in relationships, NPD individuals act in a way to reduce that possibility by destroying interpersonal 252

relations. It is evident from the literature that NPD behavioral characteristics reflect Glasser’s “seven deadly habits.”[1] Glasser’s seven caring habits are supporting, encouraging, listening, accepting, trusting, respecting, negotiating differences and the deadly habits are criticizing, blaming, complaining, nagging, threatening, punishing, bribing, or rewarding to control. This current letter will demonstrate that Beauvoir’s ontology can explain this paradoxical self-destructive behavior of a narcissist as endeavoring to avoid ontological authenticity, which means to accept and act in accordance with the recognition of being both a subject and an object which Beauvoir calls ambiguity, in a world of being with others. Beauvoir’s understanding of an authentic human consciousness arises from both Hegel and Sartre who recognize that humans can be subjects and objects for consciousness. Hegel argued that subjectivity is consciousness’s will to bring an object into unity with the subject’s wishes. However, Hegel also argued that the truth of self-consciousness’s identity is only validated by another consciousness. To add to Hegel’s ontology, Bauer argues that Beauvoir discovered that self-consciousness desires subjectivity to be objectified. Bauer explains the desire for objectified subjectivity pardons human self-consciousness a feeling of groundless identity, which is a consequence of the negating function of consciousness which provides consciousness the freedom to change through transcendence. De Beauvoir (1952)[2] says the desire to be objectified as a subject provides self-consciousness the fantasy of a fixed identity, which consciousness can never attain. Therefore, narcissist behavior can be ontologically understood as a wish to be fixated by another consciousness as possessing a perpetually free free subjective identity. This fake recognition provides an illusion and tranquillity for the narcissist as the narcissist attempts to veil the other consciousness’s own self-consciousness, subjectivity and personal freedom. This act of bad faith denies the truth that the recognition of identity involves continual struggle, ambiguity and incessant flux in life. Instead of struggling with the truth of ambiguity, in bad faith, consciousness struggles outward with another consciousness to objectify it’s subjectivity to delude self-consciousness that it is alleviated from taking responsibility for the authentic and ambiguous challenges posed by subjectivity through the possession of transcendence while another consciousness also enjoys this freedom. De Beauvoir (1952)[2] explains that although consciousness can assert its subjectivity and the objectivity of the other, “the other who limits him and denies him is nevertheless necessary to him: He does not attain himself except Indian Journal of Psychological Medicine | Apr - Jun 2015 | Vol 37 | Issue 2

Letter to Editor

through this reality that he is not. This is why the life of the human being is never plenitude and rest: It is lack and movement; it is a struggle”.[3] What Beauvoir means is that when the focus is on ontological truth, consciousness needs the other to attain subjectivity through recognition. Consequently, the narcissist can attempt to deny the subjectivity of the other by only identifying the other as an object, but this is futile and inauthentic because, the other possesses their own freedom to choose if the narcissist’s recognition should be validated and therefore the life of a human being is never plenitude and rest but lack, movement and struggle for recognition. In reality, although a narcissist can assert themself as essential, the other ‘inessential’ consciousness experiences itself as essential to the narcissist and through a dialectical reversal, the narcissist looks inessential. However, in a positive and constructive light, this self-destructive this self-destructive dialectic of essential and inessential consciousness can be transcended through authentic awareness of reality, which consists in the “the free recognition of each individual in the other each posing himself and the other at the same time as object and as subject in a reciprocal movement”.[3] Therefore, to remove the illusory self-destructive behavior, which prevents selfobject transferences, an authentic mutual recognition is required, which occurs when both consciousness’s recognize itself and the other consciousness as dialectically ambiguous objects as well as subjects. The aversion to this mutual recognition by narcissists can be explained as an attempt to deny the truth of its difficulty “incapable of fulfilling himself in solitude, man in his relationships with his fellows is ceaselessly in danger: His life is a difficult enterprise the success of which is never assured”.[3] As a result of the inherent effort involved in maintaining the recognition of authentic ambiguity, narcissistic personalities have developed a desire to be objectified with abundant freedom by others through an illusion that they have achieved reciprocal recognition, which allows them to indulge in the fantasy of rest, peace and a fixed identity which distances them from the perpetual groundless struggle of achieving an identity in life. In conclusion, this letter has made use of Bauer’s interpretation of Beauvoir to provide an ontological grounding to understand paradoxical narcissistic behavior. The result of the preceding analysis has led to the insight that narcissistic personalities may act under the illusion that by asserting their subjectivity and the objectivity of another consciousness, the other consciousness provides the narcissist a feeling

Indian Journal of Psychological Medicine | Apr - Jun 2015 | Vol 37 | Issue 2

of uninhibited freedom for their subjective desires and wishes, which acts to provide tranquility from the perpetual struggle of their ambiguous subject-object being. Unfortunately, this understanding is inauthentic because another consciousness possesses its own subjectivity and is not an object as the narcissist may like to believe. As a result, while narcissist personalities may choose to objectify another consciousness without subjectivity to escape the struggle of the truth of existence that accompanies ambiguity, they will live in a world of bad faith, inequality and nihilism that arises without the reciprocal recognition of the true meaning of existence. Finally, these brief comments are important as they provide the possibility of widening a psychotherapist’s understanding of narcissism to ontologically guide their treatment approach for their clients.

Matthew Gildersleeve Faculty of Humanities and Social Sciences, The University of Queensland, Brisbane, Australia Address for correspondence: Dr. Matthew Gildersleeve, Faculty of Humanities and Social Sciences, The University of Queensland, Brisbane, QLD 4072, Australia. E-mail: [email protected]

REFERENCES 1. Gildersleeve M. Demystifying paradoxical characteristics of narcissistic personality disorder. Indian J Psychol Med 2012;34:403-4. 2. De Beauvoir S. The Second Sex (trans. HM Parshley, 1974). New York: Vintage; 1952. p. 38. 3. Bauer N. Simone de Beauvoir, Philosophy, & Feminism. New York: Columbia University Press; 2001. 4. Kohut H. The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders: University of Chicago Press; 1971. 5. Banai E, Mikulincer M, Shaver PR. “Selfobject” needs in Kohut’s self psychology: Links with attachment, selfcohesion, affect regulation, and adjustment. Psychoanal Psychol 2005;22:224. 6. McLean J. Psychotherapy with a Narcissistic Patient Using Kohut’s Self Psychology Model. Psychiatry (Edgmont) 2007;4:40-7. Access this article online Quick Response Code Website: www.ijpm.info

DOI: 10.4103/0253-7176.155683

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