Thin-skinned or vulnerable narcissism and thick-skinned or grandiose narcissism: Similarities and differences

Abstract

This paper explores two clinical forms or aspects of narcissism and their psychopathological implications: thin-skinned, or vulnerable, narcissism (VN) and thick-skinned, or grandiose, narcissism (GN). The different names used and the characteristics with which they have been described are reviewed. Clinical vignettes are examined for both types of narcissism, emphasising their diagnostic characteristics and discussing their similarities and differences, in addition to the factors that may confer additional complexity to the clinical case. The importance of the experiences of shame and humiliation are emphasised. Based on these comparisons, the psychodynamic mechanisms at play are examined in both cases, especially their relation to the levels of mental functioning. The paper concludes that both VN and GN constitute failed ways to face the difficult dialectic articulation between self-affirmation and acknowledgement of the other.

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The International Journal of Psychoanalysis
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Thin-skinned or vulnerable narcissism and thick-
skinned or grandiose narcissism: similarities and
differences
Ricardo Bernardi & Mónica Eidlin
To cite this article: Ricardo Bernardi & Mónica Eidlin (2018) Thin-skinned or vulnerable narcissism
and thick-skinned or grandiose narcissism: similarities and differences, The International Journal of
Psychoanalysis, 99:2, 291-313, DOI: 10.1080/00207578.2018.1425599
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Thin-skinned or vulnerable narcissism and thick-skinned or
grandiose narcissism: similarities and differences
†
Ricardo Bernardi and Mónica Eidlin
Asociación Psicoanalítica del Uruguay, Montevideo, Uruguay
ABSTRACT
This paper explores two clinical forms or aspects of narcissism and
their psychopathological implications: thin-skinned, or vulnerable,
narcissism (VN) and thick-skinned, or grandiose, narcissism (GN).
The different names used and the characteristics with which they
have been described are reviewed. Clinical vignettes are
examined for both types of narcissism, emphasising their
diagnostic characteristics and discussing their similarities and
differences, in addition to the factors that may confer additional
complexity to the clinical case. The importance of the experiences
of shame and humiliation are emphasised. Based on these
comparisons, the psychodynamic mechanisms at play are
examined in both cases, especially their relation to the levels of
mental functioning. The paper concludes that both VN and GN
constitute failed ways to face the difficult dialectic articulation
between self-affirmation and acknowledgement of the other.
KEYWORDS
Narcissism; identity; self
Introduction
The term “narcissism”is generally used at the clinical level to indicate a tendency toward
the grandiose self-affirmation, along with a lack of awareness or consideration toward the
other. These ideas were already present in early clinical work on the topic. In 1931, Freud
(1990) described a narcissistic character that differentiates men who impose themselves
upon others as “personalities,”able to both support others and take on the role of
leader. Similar ideas are found in the pioneering contributions of Reich [1933](1945).
Reich identified the existence of a phallic/narcissistic character that expresses itself
through arrogance, self-confidence, and dominant attitudes. The idea that exaggerated
self-affirmation accompanies a devaluation of the importance of the other is consistent
with the Freudian metapsychological conception that the narcissistic libido and object
libido behave like a system of communicating vessels, such that an increase in one
leads to a decrease in the other.
Over time, other ways of observing the clinical phenomena typical of the narcissistic
pathology and of conceiving of its nature have arisen. For example, for Kohut (1977), it
is not that the narcissistic libido becomes object libido, but rather that both follow their
© 2018 Institute of Psychoanalysis
CONTACT Ricardo Bernardi bernardiric@gmail.com Santiago V·zquez 1144, Montevideo, 11300, Uruguay
†
This work was first presented at the Psychoanalytic Association of Uruguay on 10 June 2015 and an earlier version pub-
lished in 2016 as “Narcissism of thin or vulnerable skin and thick skin narcissism or grandiose: similarities and differences”
in the Uruguayan Journal of Psychoanalysis 123:73–103.
INT J PSYCHOANAL, 2018
VOL. 99, NO. 2, 291–313
https://doi.org/10.1080/00207578.2018.1425599

own paths of development throughout life. In archaic narcissism, the other does not lose
his or her importance; rather, narcissistic transferences, whether they are grandiose or
idealising, show that the other, experienced as a self-object or as part of oneself,
plays a fundamental role. Many of these ideas have greatly influenced many currents
of contemporary relational psychoanalysis, yet they are in opposition to those of
other authors, such as O. Kernberg, who prioritise the role of aggression and the primi-
tive defences that limit the possibility of developing profound relationships. For Rosen-
feld (1971), too, pathological narcissism is characterised by an omnipotent, envious, and
destructive self. French psychoanalysis took a different direction. If we consider each
author's perspective we find that while Kohut emphasises the immature character of
pathological narcissism, and Rosenfeld and Kernberg focus on aggression, Green
(1994) highlights the phenomena of disobjectalisation, which distinguishes thanatic nar-
cissism from trophic narcissism. Similarly, Lacan emphasises the immobilising role of the
movement of desire, blocked by the aspiration to completeness.
We particularly focus here on a distinction on which authors from diverse theoretical
traditions agree; namely, the differentiation between thick-skinned or grandiose narcis-
sism (GN) and thin-skinned or vulnerable narcissism (VN). Although this distinction has
been made by many authors, its importance for psychoanalytic theory and clinics has
not been sufficiently discussed in the current international literature. Therefore, we do
not compare the different metapsychological approaches to the clinical forms of narcis-
sism described in the text; instead, the focus of our contribution remains in the clinical
field. We emphasise the significance of some of the clinical and theoretical problems
that arise from recognising the vulnerable forms of narcissism and the importance of dis-
cussions about their relation to the classical forms of grandiose narcissism. It is no longer
possible to think about narcissism merely as the phenomenon of a return from the libido
to the ego, nor can we focus exclusively on grandiosity or equate such grandiosity with an
aggressive disregard of the other. The distinction between different forms of narcissistic
phenomena enriches our psychopathological understanding and therapeutic approaches
and helps to better understand the complexity of the processes that underlie recognition
of the self and of the other. From a theoretical point of view, we want to highlight a model
of thought in which the psyche is conceived of as an open and dynamic structure. From
this position, the self/other, internal world/external world dialectical relationship emerges
as important for the constitution of narcissism and of both its grandiose and vulnerable
aspects.
Thin-skinned or vulnerable narcissism and thick-skinned or grandiose narcissism
The two forms of pathological narcissism have been given different names in the litera-
ture. Some authors write of thin-skinned and thick-skinned forms of narcissism (Rosenfeld
1987a; Kernberg 2014). Others term it grandiose versus vulnerable narcissism (Akhtar and
Thomson 1982; Cooper and Ronningstam 1992; Dickinson and Pincus 2003; Caligor, Levy,
and Yeomans 2015).
Other denominations have also been used, which we review here as they illustrate
central ideas about the topic. Gabbard (1989) distinguishes between indifferent or obliv-
ious narcissism and hypervigilant narcissism. Britton (1989) writes of hypersubjective and
hyperobjective patients. Russ et al. (2008) write about grandiose, malignant forms versus
292 R. BERNARDI AND M. EIDLIN

fragile forms, also referring to characteristics at the level of functioning and exhibitionism.
Ronningstam (2009) distinguishes arrogant, open, grandiose, assertive, aggressive narcis-
sism from shy, covert, vulnerable, shame-driven narcissism.
These distinctions require us to include in the core of the narcissistic pathology not only
grandiose or triumphant aspects, but also painful internal experiences of vulnerability,
inferiority, emptiness, boredom, fear, and lack of self-confidence. This then begs the ques-
tion of how to articulate these two aspects. Are there two different types of patients, or are
the two aspects present in the same patient?
Rosenfeld (1987b), who as mentioned above was one of the first to make this distinc-
tion, proposes the existence of two types of narcissistic patients. “Thin-skinned”patients
are fragile, vulnerable, hypersensitive, easily hurt, and find it very difficult to deal with
any trauma or failure. In contrast, “thick-skinned”narcissistic patients are oblivious to pro-
found feelings, inaccessible, and characterised by intense envy that leads to a devaluation
of the analyst and analysis, as well as of any dependency situation.
Akhtar (1989,2000) and Akhtar and Thomson (1982) note that, along with the presence
of overt aspects related to grandiosity, there may be other covert aspects, such as self-
doubt, envy, etc. They, therefore, do not emphasise two sub-types of the narcissistic per-
sonality; instead focusing on overt aspects along with others that remain hidden.
Overt, grandiose narcissism was described by Kernberg (1975, p. 295) as the principal
characteristic of pathological narcissism, characterised by the investiture of a pathological
structure of the self, the grandiose self, dependent upon the admiration of others and
hypersensitive and vulnerable to rejection. Along these lines, Caligor, Levy, and
Yeomans (2015) add that what characterises the narcissistic personality disorder in
general, whether it is grandiose (overt) or vulnerable (covert), is a feeling of fragility of
the self that endeavours to maintain its self-perception as someone exceptional. In any
case, for these authors, the two sub-types are extraordinarily egocentric and, in both
cases, the specific pathology of identity formation that characterises the narcissistic dis-
order (Kernberg 1975,1985) is also expressed through difficulties in interpersonal
relations; both have a profound need for an other who can reaffirm their self-esteem.
Pincus and Lukowitsky (2010) point out that both narcissistic aspects—grandiose and
vulnerable—can be expressed in both covert and overt ways in how patients think, feel,
behave, and participate during treatment. Dickinson and Pincus (2003) indicate that,
despite the differences between the two narcissistic sub-types, feelings of self-affirmation
and exploitation in interpersonal relations are found in both. According to Bateman (1998),
movement between a clear position of grandiosity and a clear position of vulnerability can
increase the possibilities of enactment in the form of aggression toward others when thick
skin predominates, and as self-aggression when thin skin prevails. For this author, patients
who move between the two positions are more susceptible to analysis, as their identifi-
cations are not as rigid. Britton (2004) adds that both qualities, thin skin and thick skin, fra-
gility and toughness, alternate in turn between the patient and the analyst; they are the
result of two different relations between the subjective self and a third object within
the internal oedipal situation. For Britton, the third object is the analyst’s objective
version of the patient’s subjective experience; that is, when the analyst exercises his or
her mental function independently of the intersubjective patient–analyst relation. In
both thin-skin and thick-skin situations, the third object is alien to the subjective, sensitive
self. These patients (Britton 1989) do not dare imagine a relationship with their analyst, a
INT J PSYCHOANAL 293

primary object, as a third object with his or her own ideas, communicating with him or
herself about the patient, because this would represent a threat to their own subjectivity.
The common countertransference reactions of analysts to grandiosity or vulnerability
oscillate between feeling idealised and like the only ones able to provide a magical
cure, and feeling like they have nothing to offer and are devalued, incompetent,
ignored (Betan et al. 2005; Russ et al. 2008; Gabbard 2009; Caligor, Levy, and Yeomans
2015), impatient, exploited, or inhibited and fearful of hurting a hypersensitive patient
(Pincus, Cain, and Wright 2014). These countertransference reactions are useful for diag-
nosing pathological narcissism (Gabbard 2009; Pincus, Cain, and Wright 2014).
Note that, while authors such as Kernberg see grandiosity as grandiosity of the self
(Kernberg 1975), for other authors such as Kohut (1971), while grandiosity in narcissism
can refer to the self, giving rise to mirror transferences, it can also be aimed at exalting
the object (self-object), as is the case in idealising transferences.
With respect to VN, Rosenfeld (1987b) and Bateman (1998) put forward a different clini-
cal approach to this type of patient. Kernberg maintains that the more severe the case, the
more that interpretations should address the primary nature of the aggression. In contrast,
Rosenfeld and Bateman reject the idea of interpreting the most destructive aspects,
because this may inhibit the patient’s possibilities for self-affirmation and ability to con-
struct satisfactory object relations, enhancing feelings of vulnerability. According to
Bateman (1998), these vulnerable patients feel shame when they feel rejected. As a
result, they seek agreement with the object, thereby denying the differences. It is in this
sense that the author defines them as object-denying.
For these authors, it is important to preserve the positive aspects of their internal world,
as thin-skinned/vulnerable patients find it very difficult to face any trauma or failure. The
danger in closeness to the other is, in turn, highlighted by Caligor, Levy, and Yeomans
(2015), who point out that vulnerable patients seek to withdraw from social situations
when their own unfavourable evaluations of themselves with respect to others provoke
intense feelings of shame, pain, or envy, in line with covert expectations of grandiosity.
According to these authors, it is common to observe in these types of patients depression,
anxiety, non-suicidal self-injury, and suicide attempts (Miller and Campbell 2008; Russ et al.
2008; Pincus and Lukowitsky 2010). This type of depression, Pincus, Cain, and Wright
(2014) suggest, is characterised more by feelings of emptiness, uselessness, and suicidal
ideation than it is by grief and sadness. They note that it is at this point that patients
consult, feeling afraid of being let down and ashamed of needing others, yet, despite
this, they are subjects who, when their demands for recognition are not met, have out-
bursts of rage and hostility that culminate in shame and depression. This fluctuation
affects their emotional lability and the fragility of their self-esteem (Pincus 2013). Accord-
ing to Pincus (2014), the analyst’s countertransference feelings of incompetence and use-
lessness help to recognise the place that the patient is assigning to the analyst from a
position of grandiosity that is not visibly apparent.
With respect to the technical aspects, for Britton (2004), thin-skinned or “hypersubjec-
tive”patients seek to incorporate the analyst into their subjective world and eliminate any
differences between the analyst’s person and the patient’s interpretation of him or her. It is
very difficult for them to tolerate the third position of the analyst. They seek a positive,
skin-deep, and enveloping transference to what they consider an “intersubjective
(maternal) transference,”which has many points in common with Bick’s(1968) description
294 R. BERNARDI AND M. EIDLIN

of adhesive identification and Meltzer’s(1975) adhesive identification. The third object,
with objective and penetrating understanding, which feels dangerous, is the object of a
negative transference.
With respect to grandiose narcissism, Caligor, Levy, and Yeomans (2015) indicate that
maintaining a grandiose sense of oneself requires a withdrawal from or denial of those
facts that put one’s grandiosity in doubt, such as showing a patient, for example, that
others may possess attributes that he or she lacks. These patients are subjects who may
be relatively free of a subjective imbalance, unless they come up against professional or
interpersonal failures (Kernberg 1975; Ronningstam 2005). For Russ et al. (2008), the
characteristics of grandiosity tend to be related to substance abuse and present comorbid-
ity with antisocial or paranoid personality disorders.
Bateman (1998) takes the idea of the idealised self in thick-skinned patients and ident-
ifies it with a self-destructive self, whose purpose is to triumph over life and creativity.
These are difficult patients to keep in treatment, as they scoff at the interpretations of
their needs and dependency, they reject so as not to be rejected, and they maintain an
impenetrable attitude of superiority. The analyst is experienced as someone who wants
to destroy the idealised self and generate dependency. Given these characteristics, the
loss of analysis or of the analyst, or of any external object, is not experienced with pain;
rather, quite the contrary, it fills them with feelings of excitement and triumph. As a
result, analytic sessions are dominated by defensive attitudes and a desire to destroy
the analyst as a source–object of goodness and personal growth. According to this line
of thought, the thick-skinned narcissist is defined by the author as “object-destroying.”
Along these lines, Britton (2004) states that these patients seem immune to the analyst’s
interpretive comments, while they seek an alliance with the analyst from a rational pos-
ition, accepting the cognitive clarifications, yet rejecting the emotional. He defines them
as “hyperobjective”; they avoid subjectivity and seek the third object as a source of objec-
tive knowledge.
Disagreements largely revolve around aggression. For some authors, as we have seen,
aggression is an essential, primary phenomenon associated with grandiosity, while for
others such as Kohut, aggression toward the other is not primary, but rather the result
of a failure to establish an empathic relation that would make it possible to feel the
other as part of oneself (an attitude that the analyst can feel to be aggressive if he or
she does not understand it). This position can be tied to that put forward by Winnicott,
who maintained that, at the beginning, aggression is part of love, and its purpose is not
to destroy the external object (stage of pre-concern). “Destruction only becomes an ego
responsibility when there is ego integration and ego organisation sufficient for the exist-
ence of anger, and therefore of fear of the talion”(Winnicott 1975, p. 210).
In these discussions, it is difficult to say to what extent it is different types of patients
that are being talked about and to what extent it is that there are difficulties in the dialo-
gue between different psychoanalytic traditions (Bernardi 1989,2001,2017). As we have
said, it is not our intention here to integrate the different contributions and perspectives
based on certain metapsychological principles or to explore the similarities and differ-
ences between these principles. We believe it is more useful to take note of the complexity
they reflect and use it as a source of indications or guidelines for exploring clinical cases,
leaving the last word to the clinical cases themselves.
INT J PSYCHOANAL 295

Clinical case: Mrs A
Mrs A, 27 years old, married, and referred by a psychiatrist, reported feeling very depressed
and anxious and having strong contractures in her neck over the past year. In the first
interview, she said that, despite feeling so bad, she strongly disliked asking for help.
She described herself as someone who always solved all her problems without needing
to ask anyone for anything. As a result, when she came up against her difficulties, her
anxiety took on such intensity that it would culminate in intense outbursts of anger
that contaminated all her relationships. She described her adolescence as a period of
great confusion. She went to live with her boyfriend at 14 years of age, which was followed
by different partners and addresses and by drugs and alcohol. She had serious problems
with impulsiveness and violence that she was unable to control. She had had several part-
ners who only lasted a few months. At 21, she met her current partner, with whom she had
three children. She was able to form a family and had been emotionally stable for almost 6
years. She finished her studies and had been working in retail for several years.
Mrs A has one brother and one sister, both younger than her. Her parents separated
when she was at school, and her father left the family for years while he was in a
number of relationships with other women. Until the separation, she had been convinced
that her family was perfect, but after the separation, everything fell apart. Economically,
she had to help support the household. She admitted never having told her father how
angry she felt for his having abandoned them. She would often recall this abandonment
between tears and rage. At the same time, she would emphasise moments when he had
made her feel like the prettiest in the house, but that would all quickly become permeated
with very violent paternal interference that stripped her of everything. Her father suffered
from depression.
Mrs A blamed her mother for having forgiven her father for his infidelity. She argued
hotly with her because she valued her siblings more than her. Her mother was a home-
maker, who always felt frustrated about not having finished her university degree.
My mother would always do things in the house, she never let us want for anything, she was
never there for us (smiles), but all things considered, she raised us well. She is like me, “I can do
it,”demanding, you have to achieve what you set out to do.
She was a mother who was present for her children—controlling but affectively detached.
According to the patient, her mother was interested in her when she achieved certain
successes.
Following the family crisis, Mrs A grew up feeling like the world was a dangerous place
that could strip her of her most treasured things. She spent most of her time working
almost obsessively in order to earn a lot of money, recover the “family’s dignity,”and
fulfil the maternal mandate that she should always get whatever she wanted, all as a
way to gain her mother’s approval. She described herself as impulsive, crazy, but a
good person, very demanding with herself and with money. She recognised that she
would say what she was thinking in hurtful ways, just like her father, and that she did
not feel sorry if she hurt someone, because she was always right and very rarely made mis-
takes. She knew she was arrogant; everyone told her that “she knew it all,”and that is why
her friends depended on her, as well as all her partners, who, according to her, ended up
imitating her in everything. She said that sometimes she wanted to live alone and very far
296 R. BERNARDI AND M. EIDLIN

away, because she didn’t need anybody. She tired of the bonds of absolute dependence
that others created with her.
Her depression began when she ended a business partnership with a friend that was
not working well and losing a lot of money. She started to have contractures at the
base of her neck, which led to the need to consult different doctors. “I want to have every-
thing under control, including my health. I hate seeing doctors; it depresses me”…“Iam
very ambitious. I want to have more and more. I have become a producing machine.”She
blamed her business partner for what happened and permanently ended their relation-
ship. This episode, along with seeing herself as sick, brought about a nervous breakdown,
which led to depression with strong emotional reactions of anger and shame. During this
period, she was assaulted, her father had a stroke, and her brother was diagnosed with a
dangerous cancer. This last point she reported without any concern or pain. She said that
she felt furious about what was happening to her, angry at life, and that her mind was
telling her that she had to hurt herself and that she deserved to suffer. However, what
hurt her most at that time was that she could not change what had happened to her.
Even so, she tried to maintain a perception of herself as someone superior through the
power of aggression, or she would engage in endless sexual affairs as a way of feeling irre-
sistible. At first, she enjoyed these erotic encounters, but if she felt that the man was
becoming too tied to her, she was afraid that he would strip her of everything she had
to give: “you give, give and give and then they take advantage and they take everything.”
The relationship would end abruptly, and she would react indifferently, with no nostalgia,
grief or guilt, as the object of her erotic satisfaction had become someone contemptible.
She would arrogantly brag that she had never been abandoned by any man and about her
ability to drive men crazy sexually.
Mrs A’s treatment took place twice a week. Because of her financial difficulties, it was
not possible to increase the number of sessions. At the start of analysis, the patient’s atti-
tude showed a strong ambivalent transference. On one hand, she described herself as
looking forward to the session because she believed her analyst understood her better
than anyone; on the other hand, she would sometimes arrive late, with only 10 minutes
before the session would end, or she would not show up at all without any prior notice,
or she would not take into account anything the analyst said. In countertransference,
the analyst (one of the authors of this paper) experienced feelings of impotence and frus-
tration with this behaviour. Although there were interpretations, her analyst, just like her
husband or current lover, simply had to listen to her and help her feel better, but if the
analyst tried to show her something that was different from what she was thinking, she
took it as an attack on her person. This would lead the patient to a sense of losing
control and omnipotence, which she did not hesitate to restore and bring back to the
fore with mocking, dominant, and hostile behaviour. Her analyst ceased to occupy the
place of someone able to solve all her problems and quickly became someone incompe-
tent, only interested in taking her money. Any possible usefulness of the analyst was, thus,
destroyed.
Patient: I stopped taking the medication.
Analyst: Did you talk to the psychiatrist?
P: No, I decided myself.
A: Last week I couldn’t see you, and you decided to stop taking the medication.
INT J PSYCHOANAL 297

P: I don’t understand what you’re saying (in an irritated and provocative voice)! I
stopped taking it because I don’t want to take so many drugs, I don’t want to
depend on the pills! I’m very anxious and very aggressive, too, but I don’t want
to depend on anything.
A: It seems like you are very angry because I had to cancel two sessions. We could
think about if it bothers you just to depend on the pills, or also on the treatment.
It’s important to take a few minutes to note what is happening right now. I couldn’t
see you last week, you stopped taking the pills, and you feel worse. What connec-
tion is there between all these situations? Could it be a way of making me feel that
this treatment is useless? At the same time, by deciding all by yourself, you are
getting rid of any type of help anyone can offer you.
P: I can’t handle depending. Yes, yes, before I did everything alone, What? Are you
going to tell me that it’s bad to always have handled everything alone?! That I
always needed psychoanalysis, blah blah blah. (Looks at the analyst with some con-
tempt.) I don’t know if you’re trained to understand me (said while smiling); my life
is pretty complicated. I think it would take years of study, and this therapy is costing
me a lot of money.
A: It seems to me that you have the idea that if this type of medication is discontinued
abruptly, you’re going to feel really bad.
P: Yes, and? (defiant)
A; So, you try to feel bad so that I feel like I’m not able to help you? From your smile, it
seems like you feel some pleasure from turning me into a bad analyst. Not only am I
unable to understand you, but on top of it, I charge you.
P: I don’t know if that’s how it is, I feel a lot better.
It was striking how once the depression started, and at moments of crisis, her psyche
was occupied by alternating grandiose and vulnerable aspects, as well as their coexis-
tence. She would say between tears that she wanted to separate from her husband, but
that she did not dare. She was very afraid of being left alone. When she put herself in
this place, her capacity for reflection disturbed her, endless thoughts flooded her mind,
and she could not distinguish between her mother’s attitude toward her children and
her own toward her own children, her father’s leaving, and her fear that her children
would be left without a father. Yet at the same time she felt a lot of anger about what
she interpreted as weaknesses that hurt her self-esteem, which she would try to
strengthen with contempt for her husband; she would say that he was useless and that
she had to support him. She would go from feeling like a helpless girl, terrified of being
abandoned, to a state of omnipotence. It was all as if something threatening were hover-
ing above the analytic space. More than once, the analyst felt a certain affective distress
that she was unable to explain consciously and that, as a result, she was unable to trans-
form and communicate to the patient. She understood that, for Mrs A, her loss of the illu-
sion of grandiosity meant something similar to the impact it was having on her as the
analyst: uneasiness, restlessness, anxiety.
P: I haven’t broken off my relationship with the father of my children. Last week I wasn’t
well, I was depressed, he saw me unwell and said things that hurt me, that I’m a bad
mother, that I leave my kids lying around, whatever hurt me. (Cries.) I have to go take
a pill and go to sleep.
A: You are saying that you are with a person who makes you feel like a bad mother, who
mistreats you. When I say this, what do you think?
P: Nothing, that I’m an idiot. But he is the father of my children. (Cries.) And he knows that
I’m really afraid of my children being alone, without a father, and having a hard time, and
298 R. BERNARDI AND M. EIDLIN

for them it would be my fault that their father isn’t there (very upset). But I’m also realis-
ing that when he is there my kids have a hard time, in a tense environment with arguing,
abuse, it can’t be. I shouldn’t see him ever again.
A: You get very upset when you talk about your fear that your children will be left alone
without a father. Sometimes it seems like you are talking about your own fears of
being alone.
P: (Cries.) I don’t want …I don’t know if I’m sick or what, something is going on, I don’t want
to see his face again. It’s hard for me, it isn’t easy, I don’t know why I can’t break off the
relationship. It’s so hard (cries with great anguish). Everything was going well before, I
was earning a lot of money, now I’m a different type of person and I can’t be okay
with him. He can’t stand who I am, I disgust him.
A: Let’s think for a moment about some things you said: you’ve told me that you got along
well when it was you who was covering the household expenses. The situation changed,
and you also got sick, and he started to treat you differently. But maybe you should con-
sider if you allowed him to mistreat you because you couldn’t stand seeing yourself in
that new situation. You feel like you lost control, you lost power. Let’s consider that
maybe you couldn’t stand seeing yourself sick, and maybe it was you who was disgusted
with yourself from seeing yourself in this situation. What do you think about what I am
saying?
P: Yes, I can’t stand myself (cries), I can’t see myself like this, I was never like this.
A: You feel worthless and you let your spouse mistreat you? Do you think that I do the same
thing your husband does?
P: (Silence.) I never thought that (said in a calm, almost imperceptible tone). Look, if
they see you on the ground they step all over you, but if you’re the powerful one,
no one screws with you!! (Her voice suddenly changes radically, becoming abrupt,
threatening. The analyst felt startled and struggled to find a connection between her
stories).
Mrs A revealed her feelings of vulnerability, yet the analyst did not perceive a real inte-
gration of negative and positive affects, which would lead to a countertransference reac-
tion of compassion or concern. Instead, she felt that the patient’s lament, far from
empathising with others, was marked by an intense hostility connected to an emotional
experience of self-devaluation, upon which it was difficult to reflect. The remainder of
the session corroborated this countertransference perception.
P: I don’t know what is going on, my relationship with my husband is out of my hands. It’s
bad for me to be with him, but I can’t entirely kick him out. It’s infuriating! I would kill him
without a problem! (Cries.)
A: You feel a lot of rage. Why are you crying?
P: It’s that I’m lost! (Cries loudly and yells.) I can’t, I can’t. This shitty little office employee,
and I still have to support him (cries). History is repeating itself and I’ve been going
through the same sequence for years and I can’t go on like this. He is a person who
hurts me, he’s bad for me, bad, I’m tense and I have to take a thousand pills. I’m afraid
of ending up alone, I’m so afraid (cries loudly and hits her leg). I mistreat him and he
tells me I’m a slut who goes out with other men. I wish he would die and all my problems
would end! I don’t know what I’m going to do with my life. I don’t want my children to
end up without a father, I don’t want them to suffer (goes from crying to uncontrolled
rage). The only thing I want is to lie down and not do anything (cries loudly for a long
time). I miss him because I’m used to him being there. I remember when I went to
Peru for 4 months and I missed him terribly, but I don’t need him to live, I can do it
alone (she says this as she stands up as the session has ended; the crying stops and
her look of contempt returns).
INT J PSYCHOANAL 299

We would like to emphasise Mrs A’s lack of empathy and ability to establish close
relationships. She required the immediate attention of others, and was indifferent to
the effect that her demands for appreciation had on others, as Gabbard (1989) indicates.
Others mattered to the extent that they reinforced her narcissistically. It was only for her
children that Mrs A was able to feel pain, concern, and guilt. At times, these feelings
seemed to correspond to a healthier part of her self, while at other times they were
mixed with more idealised aspects, where her fear of failure with respect to her ideal of
mother would appear.
While she was working and earning money and occupied a social place of privilege, she
was able to maintain her grandiosity intact and everything apparently worked well. It was
a grandiosity that did not appear to be associated with overt aggression, but, rather, with
the exercise of social and economic power and the admiration of others. When she failed
in business, she lost her economic position and got sick, had a breakdown, and got
depressed, and from there her actions and contempt toward others worsened. Coming
up against a poor and unstable self, realising that she could not give “two hundred
percent in everything,”exposed her to: “either you can do everything or you suck.”This
gave rise to a narcissistic injury that humiliated her and made her feel worthless, unleash-
ing a relentless narcissistic rage that led on one hand to self-aggression, cutting her arms,
but also contaminated all her relationships; she distanced herself from her friends, felt that
she could not care for her children, and especially attacked her relationship with her
husband. She needed to devalue him as a way of destroying him as a significant object,
in order not to recognise her need for dependence and, hence, her own shortcomings.
She was more ashamed about her humiliation from feeling diminished in front of
herself and her friends than she was about her guilt for having hurt them. As a result,
she withdrew socially because she did not want them to see her like that, although she
persisted in her pursuit of sexual contexts that would fill her with feelings of excitement
and triumph: “I drive them crazy sexually and then I kick them out.”Her struggle is directed
at not letting herself be dominated by her weaker aspects.
Clinical case: Mrs B. Is it possible to recognise vulnerable narcissism in the first
interviews?
In the previous case, we saw the characteristics of pathological narcissism when grandiose
aspects predominate, which make it difficult for patients to express their more fragile
aspects. In Mrs B’s case, in contrast, her vulnerable aspects are in the forefront. Our inten-
tion here is not to present the treatment of a patient of this type in extenso, which would
not be possible due to space limitations, but rather to emphasise those overt character-
istics that allow us to identify the patient within the narcissistic pathology. The narcissistic
nature of the suffering of these patients is often not easily recognised at first, thus we focus
our discussion here on the diagnostic problems as they present right from the first
interviews.
Mrs B had a major depressive episode and feelings of uselessness, devaluation, and fear
of criticism. She behaved extremely politely. She always tried to do her work the best she
could, although not receiving the approval she expected would disappoint her. She felt
that others did not appreciate her efforts to achieve perfection. They would tell her that
she saw the trees, but not the forest. She did not understand why they would say this,
300 R. BERNARDI AND M. EIDLIN

as she tried to take everything into account. As a result, she would withdraw. She did not
like to expose herself. Her social life was very limited. After a romantic experience that fru-
strated her, she did not have another partner. She felt different from others, without being
able to say why. Her few friends were similar to her, withdrawn. She would only do things
she felt would go well. Her childhood was difficult, due to her mother’s depression and
hostility—her mother was always rigid and critical of her—and also due to her father’s
alcoholism and depression, which kept him away from family life.
We have taken this case (in shortened form) from Skodol et al. (2015), as it is one of the
examples upon which the proposal to include VN in the DSM is based. This proposal was
partially accepted when it was included in section III as an issue for future study. It signifi-
cantly modifies the definition of narcissism in the DSM-IV, which considers grandiose nar-
cissism exclusively. However, why consider narcissistic disorder to be central in Mrs B and
not other disturbances that could, at first sight, also explain her problems, such as social
phobia? Like Skodol et al. (2015), we consider that the differential diagnosis between the
two is fundamental, and we think that it is useful for analytic work.
Careful examination shows that, although her withdrawal may be explained as social
phobia or avoidance disorder, the core of Mrs B’s disorder is not her fear of being over-
whelmed by her anxiety in social situations; rather, it lies in her hypersensitivity to negative
evaluations that affect her aspirations for perfection. Her difficulties relating to others arise
from this and lead to her inhibition and social inadequacy. Her central problem is related
to her need to regulate her self-esteem through the approval of others. She needs her per-
fection to be confirmed—a difficult aspiration to perceive, as it remains covert and is only
expressed through her self-imposed demands. She, thus, alternates between an expec-
tation that her grandiose perfection will be acknowledged and a fear of experiences
that will frustrate and shame her, hence she sees social withdrawal as a solution. While
avoidance disorders also lead to hypersensitivity to criticism, in Mrs B’s case there is an
added difficulty with perceiving what others expect from her and how they evaluate
her performance. She only sees her own expectations and is not able to place herself
empathically in the place of those who see her performance differently. Along with her
lack of empathy, she has difficulties with intimate relationships because others interest
her more as a source of self-esteem than for who they are. There is little reciprocity of feel-
ings, as the other is, above all, a means for regulating her self-esteem. All this confirms the
central place occupied by the narcissistic disorder in her personality.
Grandiose or vulnerable narcissism and level of mental functioning
To understand these two presentations of narcissism, it is useful to examine the level of
mental functioning in each case.
Classic diagnoses, both in psychoanalysis and in psychiatry, have been predominantly
categorical in nature, emphasising the type or category of the observed disorder (obses-
sive, phobic, etc.). Today, there is also interest in dimensional diagnoses of the degree of
severity of the disorders.
The works by Kernberg (1970) were pioneering in determining the criteria for assessing
the severity of personality disorders. Kernberg takes three variables into account to estab-
lish the severity of a disorder: the identity of the self (cohesion vs diffusion), defence mech-
anisms (mature vs primitive), and the sense of reality (intact or not). Based on these
INT J PSYCHOANAL 301

variables, he established a distinction between a neurotic level of personality organisation
(where there is defensive rigidity, but the self is cohesive, defences are mature, and the
sense of reality is intact), a borderline level (with identity diffusion, primitive defences,
and the sense of reality is intact, although it wavers), and a psychotic level (where the
loss of reality testing plays a central role).
Typical narcissistic disorders are located in an intermediate level between neurotic and
borderline (Kernberg and Caligor 2004). There are special forms that present extreme
severity when they accompany paranoid, antisocial, and egosyntonic sadistic traits, as is
the case in malignant narcissism (Kernberg 1984,1986). For other authors, narcissistic dis-
orders are also located within the neuroses, although with a prevalence of the archaic dual
aspects that lead to insufficient differentiation from the other, which makes access to one’s
own subjectivity more difficult (Schkolnik 1995a). Schkolnik (1995b) distinguishes between
a narcissism related to the pursuit of completeness, which is what is seen at the neurotic
level, and an archaic narcissism, where ego–not ego differentiation is compromised,
related to death anxiety.
As Akhtar and Thomson (1982) point out, narcissistic disorders share both a lack of
empathy and the importance of splitting mechanisms with the borderline level, but
they are different in terms of the greater cohesion of the self, impulse control, control
of self-aggression, and the stability of reality testing.
These distinctions correspond especially to the grandiose forms, which are the only
forms classically taken into account (DSM-IV). However, as we have seen, interest has
been growing in the vulnerable forms of narcissism. As a result, Section III (future perspec-
tives) of DSM-5 (American Psychiatric Association 2013) includes an alternative for the
diagnosis of personality disorders that is closer to a dynamic perspective. At the same
time, diagnostic systems have been developed in the field of psychoanalysis—in some
ways closely related to this alternative version in the DSM-5—which help to better under-
stand narcissistic vulnerabilities (PDM Task Force 2006; OPD Task Force 2008).
The vulnerable forms included in the alternative version of personality disorders pre-
sented in section III of the DSM-5 leads, as Skodol et al. (2015) point out, to the inclusion
of cases with a neurotic level of organisation. The narcissistic disorder is, thus, defined as
follows: “The typical features of narcissistic personality disorder are variable and vulnerable
self-esteem, with attempts at regulation through attention and approval seeking, and
either overt or covert grandiosity”(American Psychiatric Association 2013, p. 767). The
Level of Personality Functioning Scale (LPFS), one of the central criteria for making the
diagnosis, evaluates four domains of the person, two related to the Self (Identity and
Self-direction) and two related to the Interpersonal (Empathy and Intimacy). In narcissistic
disorders, at least two of these domains must be disturbed. For example, identity and self-
direction may be affected by the instability of self-esteem and excessive references to
others. The capacity for empathy and intimacy reveal, as in Mrs B’s case, the difficulty
with being sincerely interested in others, as the relationship is at the service of the
person’s self-worth.
According to this scale, Mrs B presents a moderate-level disturbance in her personality
functioning, which can be said to mean that her disorder exceeds that of a mild neurotic
level, without reaching a borderline level of severity. Applying other current diagnostic
systems with a psychodynamic orientation, such as the OPD-2 and the PDM, her clinical
302 R. BERNARDI AND M. EIDLIN

case formulation would yield similar results, as the degree of agreement between these
diagnostic systems is considerable (Bernardi et al. 2016).
The OPD-2 offers a diagnostic perspective of great practical and theoretical value;
namely, the distinction between problems generated by conflict and those related to
structural problems. From this perspective, we can see that narcissistic problems can be
related to unconscious conflicts at the neurotic level, but that there can also be underlying
problems at the level of basic structural functions that affect the regulation of self-esteem
and the perception of oneself and others. It is important to distinguish between the two, as
the possibility of the patient being able to work on his or her unconscious conflicts in
analysis is conditioned by the level of integration of these structural functions. These
include the capacity to perceive oneself and others, to regulate affects in traumatic situ-
ations, and to process emotions, communicate, and relate to oneself and to others.
These capacities, determined by multiple factors (constitutional characteristics, traumatic
experiences, and defensive styles that can perpetuate them), are the psychological foun-
dation for mental functioning and are necessary for expressing conflicts and elaborating
upon them in an organised fashion in analysis. When they fail, this is the point that psy-
chotherapy must first address.
An interview conducted according to the OPD-2 criteria would probably show an inter-
mediate level of structural integration in Mrs B, which would be consistent with LPFS
results. The conflict/structure distinction allows the analyst to determine if it is possible
to start treatment by working on unconscious nuclear conflicts or if it is first necessary
to identify compensatory pathways for the basic structural problems in order to
improve mental functioning.
We shall now try to compare Mrs B’s case and Mrs A’s case. They both present a narcis-
sistic disorder, but with different characteristics. In Mrs A, grandiose narcissism predomi-
nated until the symptoms of depression appeared, which revealed covert vulnerable
aspects. Both patients were hypersensitive to negative evaluations. Mrs B was aware of
this, and defended herself through isolation and avoiding relationships with people of
the other sex. In contrast, when Mrs A came up against the shame related to feeling
weak, she quickly sought to turn it into the opposite: exaggerated self-affirmation. She
took shelter, for example, in feeling fed up with others or thinking hostilely that she
would like to be far away from everyone, because they were the source of her suffering.
With respect to the opposite sex, she sought occasional contacts with people who she
would then look down on to regulate her self-esteem. While both patients needed exces-
sive approval from others, Mrs A was convinced that she had it until she broke down and
her fear of feeling abandoned appeared. Mrs B, in contrast, did not set out on a similar
pursuit for admiration; instead, her fear of failure led her to withdraw. The other is
someone to dominate in one case and to fear in the other.
In both cases, their capacity for mentalisation—or the reflexive function that makes it
possible to understand one’s own mind and the minds of others (Fonagy, Gergely, and
Target 2002)—was severely limited. Mrs B was unable to perceive why others might not
be happy with her work, and Mrs A responded to criticism with an aggressive attitude
that left no space for questioning herself, understanding others’point of view, or allowing
real, intimate relationships. The only way to regulate affects and self-esteem was either by
avoiding contact, in Mrs B’s case, or exaggerated and intransigent self-affirmation in Mrs
A’s. While both were able to represent and symbolise internal experiences, their capacity
INT J PSYCHOANAL 303

to integrate different representations of themselves, especially in terms of grandiose and
vulnerable aspects, was limited. In Mrs B, without coming to a situation of identity diffu-
sion typical of borderline states, her self-image and experience of her own identity were
affected. In Mrs A, during her moments of greatest decompensation, her mental func-
tioning corresponded to a borderline level, with difficulties regulating her impulses
and aggression that led her to use primitive defences. As we know, a diagnosis of bor-
derline disorder tends to improve over time (Zanarini et al. 2010a,2010b), although the
social dysfunctions persist (Gunderson et al. 2011). This is consistent with the OPD-2
idea that structural vulnerabilities can be expressed in moments of stress and then
be compensated, while certain structural deficits persist. Mrs A’s progress illustrates
this. In analysis, she was able to balance many of her behaviours: she went back to
work, became more stable in her role as mother, reduced her medication, and recovered
some of her friendships. At this point she abruptly abandoned treatment, without ana-
lysing either her need for grandiosity or her difficulties maintaining intimate
relationships.
Shame, humiliation, and depression
It is interesting to note the central place that fear of experiences of shame and humiliation
occupied in both patients, as well as the feelings of depression that accompanied these
experiences.
The “discovery”of vulnerable forms of narcissism is in line with studies of development
that show the effects of parental negligence in the face of the child’s specific needs for
acknowledgement (Van Buren and Meehan 2015). The regulatory systems of shame,
tied to the formations of the ego ideals and to the superego, begin development very
early on, at the end of the first year of life. The child’s empathic relationship with his or
her parents leads to an intense influx of excitation in the child, which is expressed
through the autonomic nervous system and probably accompanies experiences of subjec-
tive elation. Unexpected failures in attuning to caregivers can lead to abrupt changes in
the activated systems and create experiences of depletion, inadequacy, and emptiness
that are at the foundation of feelings of shame and humiliation (Schore 1991). These
specifically narcissistic traumas hinder the development of internal regulatory systems
such as the ego ideals, and, with them, the possibility of regulating the basic tone of
mood and self-esteem (Gonchar 1993). All this increases the risk of depression and the
experience of ego depletion.
Based on psychoanalytic experience, Garbarino (1986) includes a reduction in self-
esteem, a lack of trust and self-confidence, a tendency to become discouraged, and an
annoyance with life as characteristics of narcissistic depression. Unlike depressions in
which there is grief for a lost object, in these cases the lost object is the ego itself, identified
with an omnipotent ideal ego.
This threat to self-esteem as a feeling about oneself is present in both Mrs A and Mrs B’s
cases. The ideals do not transcend, nor can they safeguard the ego from the needs of the
grandiose ego. In contrast, the precarious development of the ego ideals promotes the
conservation of an omnipotent ideal ego. When the ideal ego feels hurt, it needs
revenge to recover, as the feeling of having been wronged predominates. Mrs A some-
times feels she has reached her ideal, but when she feels it is lost she experiences it as
304 R. BERNARDI AND M. EIDLIN

an attack on her dignity, which leads to humiliation and narcissistic rage aimed at reaffirm-
ing her power over the other. It is what Zuckerfeld (2014, p. 13) calls “deficit with narcis-
sistic injury,”encompassing the subjective constitution and relational configurations. For
Morrison (1989), rage is a response to shame. Mrs A’s contempt for her husband represents
the projective identification of shame. At the same time, Mrs B, when faced with the humi-
liation of not being admired by the other, withdraws to the privacy of her refuge to lick her
wounds, trying to recover by sheltering herself in her pursuit of perfectionism. From Mor-
rison’s (1989) perspective, humiliation is a response in both patients to the experience of
shame caused by their self-perception of the defects, shortcomings, and inferiorities in
themselves and in their relation to others.
A propensity for shame is statistically related to vulnerable narcissism, but not to
grandiose narcissism (Hibbard 1992). A successful narcissistic defence leaves no place
for shame and promotes a permanent pursuit of praise as a way of avoiding it
(Hibbard 1992). It is important to evaluate the strength of grandiose defences, especially
when they are egosyntonic, as they can determine the direction of treatment. This
became a significant factor in the outcome of Mrs A’s analysis. When she became less dis-
tressed, the intolerable shame she felt when expressing her weaknesses in analysis
became more evident.
In VN, it is not always external judgement that is at the forefront. It is important to con-
sider the relationship that can develop between narcissistic suffering, the judgement of
the superego, and masochism. A brief vignette can illustrate this.
Mrs C, like Mrs B, is afraid of exposing herself in public, as she anticipates the shame
she will feel if she does not perform perfectly. Unlike Mrs B, though, Mrs C is especially
skilled at her work, and her level of mentalisation enables her to realise what is expected
of her, which makes her successful. However, she cannot enjoy her successes or incorpor-
ate them into her image of herself. She feels like a fraud, and feels guilty for receiving
appreciation that she does not deserve. Achievements that seemed unattainable to
her become insignificant to her once she achieves them, or she attributes them to
chance. As a result, she must seek new challenges that are never sufficient for establish-
ing positive self-esteem. The disapproval that Mrs B fears from others, Mrs C finds in sub-
jecting herself to her own internal judgement. Over the course of treatment, she relates
these critical internal judgements to the comments she had received from her mother
since she was little. However, her real mother is not currently a main part of the
problem, nor is she as severe as her internal mother. Mrs C hesitates when, at the
level of reality, she is asked to what extent she really believes that her achievements
are worthless. She knows that they have value, but her self-criticism wins out. Her
own voice and her unharmed ego functions are unable to prevail in this battle against
the critical maternal voice that now comes to her in amplified form from within. As
Freud (1924) points out, the battle becomes especially difficult when the sadism of
the superego—in whom grandiosity is deposited—comes together with the masochism
of the ego, which draws aggression toward itself, with the resulting impact on self-
esteem. In this case, the patient permitting him or herself to obtain external achieve-
ments is just a first step; we must not forget that the decisive battle is to integrate
these achievements into the patient’s self-perception and to be able to accept the legit-
imate enjoyment they produce.
INT J PSYCHOANAL 305

Discussion
The distinction between grandiose or thick-skinned and vulnerable or thin-skinned forms
helps to better understand some of the clinically, theoretically, and therapeutically inter-
esting characteristics of narcissism.
We questioned to what extent VN and GN corresponded to two types of patients or two
aspects of the narcissism present in everyone. The cases examined show that both
answers are partially valid. Mrs A and Mrs B present different forms of narcissistic pathol-
ogy, which are useful to differentiate at the clinical level. However, it is also true that, at the
psychopathological and psychodynamic level, we find shared aspects in the two cases,
both with respect to grandiosity and vulnerability. These aspects, which are similar in
some ways and different in others, help guide analytic work.
When Mrs A’s grandiosity collapsed, vulnerable aspects appeared, but they did not have
the same qualities as in Mrs B. In Mrs A, more than thin skin, an open sore appeared, made
evident in her depression and in various types of deregulation of her affects and beha-
viours that affected her level of mental functioning. She tried to escape the feeling of
humiliation through explicit contempt toward the other, along with fierce self-criticism
and self-destructive behaviours.
This determines therapeutic management. Mrs A can accept therapeutic help as long as
it helps her regain control of her own life; beyond this point, therapeutic help becomes a
new humiliation. This tasks the analyst with a difficult job, putting his or her countertrans-
ference to the test: the analyst must maintain empathic contact, despite the patient
making the analyst feel like he or she occupies a secondary or anonymous place or as a
depository of projections. Maintaining the analytic role becomes difficult, and it is necess-
ary to be aware that the patient may choose to conserve his or her grandiosity instead of
analysing it. As we have seen, this is what happened in Mrs A’s case when she left analysis.
In Mrs B’s case, we can assume that her need for reassurance would facilitate her pursuit
of therapeutic help, although strong resistance to analysing her narcissistic suffering
would also probably arise. She could, like Mrs A, discontinue her treatment, but we
must also consider another risk. If the analyst does not properly identify the narcissistic
significance of her suffering, the analyst can become fixed in the role of a warm and pro-
tecting mother, who protects the patient’s hypersensitivity and attributes her difficulties to
other causes. While in GN the resistance to analysing narcissistic grandiosity is evident, in
VN an impasse can establish itself silently. Analysis, thus, becomes ineffective, yet endless,
as it is the analyst who provides the narcissistic supply that the patient does not dare to
seek in the external world. It is worth asking to what extent the institutional functioning of
psychoanalytic associations (and many other institutions) may be affected by the effects of
insufficiently analysed VN. This would explain, for example, the fact that, in scientific dis-
cussions, it is often difficult to present personal ideas when they are not consistent with
the dominant ideas in the institution at that time, and that all scientific discrepancies
around the value of certain ideas or authors are taken as personal attacks.
When the analyst tries to explore VN, he or she will likely find areas of thick skin in
people in whom only thin skin seemed to exist. Or, indeed, it is likely that, instead of
thick skin, the analyst will find skin that is tough and slippery or covered in barbs. Mrs B
is unlikely to give up what her perfectionism represents for her without defending it,
fleeing, attacking, or becoming inhibited. Neither should we expect in Mrs C’s case that
306 R. BERNARDI AND M. EIDLIN

she will easily stop subjecting herself to the voice of the superego, as the patient is in a
masochistic love relationship with the maternal object introjected in her ideal formations.
Perhaps the Lacanian term “jouissance”is appropriate for describing this mixture of suffer-
ing and pleasure in which transgression toward something “beyond”remains present. This
situation is evident not so much in terms of achieving external successes, but with respect
to the possibility of experiencing one’s own self as related to others in a pleasing way.
From a metapsychological point of view, we speak of narcissism when we refer to the
cathexis in oneself related to self-esteem, which may have varied different topical,
dynamic, or economic locations. These are closely related to object representations (Ber-
nardi, Díaz Rosssello, and Schkolnik 1982), and this inter-relation is fundamental for under-
standing the VN/GN polarity, which is located at the crossroads where the conjunction/
disjunction dialectic—which characterises the relation of the self with the other—is
created. To understand the development of the baby’s subjectivity and intersubjectivity,
we must pay attention both to the experiences of the self-with-other and those of the
self-versus-other (Stern 1985). Regulating the intense affects tied to systems of attachment
requires developing a sense of one’s own worth and autonomy, as well as a sense of con-
nection with others (Emde 1988). These regulatory systems do not arise as a result of
intrapsychic processes only, but rather from mutual, interactive regulations between the
child and those who care for him or her (Beebe and Lachmann 1988). These intersections
build the psyche, but they can also upset it. For example, the parents’mirroring of the child
is necessary for the child’s development, but, if it is inadequate, it disturbs the child, pro-
moting narcissistic vulnerabilities (Kohut 1971) or the phenomena of the “alien self”
(Fonagy and Target 2000). We cannot discuss here the multiple ways attachment and mir-
roring are related to narcissism, although it is important to emphasise that, throughout
development, a dialectical balance between the recognition that comes from oneself
and the recognition that comes from others is necessary. These contributions help to
understand the importance that many contemporary authors confer to the cycles of
agreement and disagreement, rupture and repair, both in analytic treatment and in
relationships in general.
The difficulty in bringing together an appreciation of the self and an appreciation of
others is not only a result of defensive splitting, but rather is largely due to the difficulty
of integrating the psyche’s opposing constitutive tendencies throughout the polarities
involved in development processes. These polarities have been pointed out from different
theoretical and clinical perspectives. Blatt (2004) describes the polarity between needs for
self-definition, or introjective needs, and those for relating, or anaclitic needs. Both dimen-
sions of the personality, which in normal development are complementary, tend to be in
opposition in the pathology (Shahar, Blatt, and Ford 2003). A contrast somewhat related to
the above is that described by LaFarge (2008) between two ways of knowing oneself—one
direct, and the other based on others. LaFarge examines the case of a patient who, at the
start of analysis, needed others (and in the session, needed the analyst) in order to be able
to construct a narrative about herself. Only gradually in analysis was she able to alternate
this knowledge based on others with the appearance of narratives constructed on the
basis of her own internal experiences. For this to happen, it was necessary for her own
story to enter into conflict with that coming from her analyst. The emergence of the
patient’s own narrative script did not in itself imply a narcissistic devaluation of the
analyst; rather, on the contrary, it entailed progress in her reflexive capacity and the
INT J PSYCHOANAL 307

need to preserve her privacy through a mutually respectful distance (LaFarge 2008, p. 195).
It is also interesting to note that, from the perspective of neuropsychoanalysis too, the
body image is exposed to a constitutive duality between the image of an “external
body”that comes from sensory receptors and mirror images and an “internal body”
that comes from internal receptors. This is an aspect that will not be developed here,
but in future work.
This perspective, based on the relation of the self with the other, is especially valuable
for those theories that confer special value to the other, both internal and external. VN and
GN bring situations to light in which the different constituents of self-representation are
unable to form an internally integrated unit that is dialectically related to others. The
notion of “bond”developed by Pichon-Rivière, Bleger and W. and M. Baranger (see Ber-
nardi and De Bernardi, 2012) implies the existence of a dialectic between the ego and
the other, between internal and external reality, between consciousness and the uncon-
scious. When these relations lose their dialectic character, the process is immobilized,
and only one of the two poles becomes dominant. The individual then attends only to
the need for self-definition, dispensing with the others and, in GN, becoming locked
into his or her own narrative script, or in VN, at the other extreme, experiencing interper-
sonal relationships as a dependency upon the gaze of others. The self is experienced as it
assumes it is seen, instead of as a function of what it feels. From a Bionian perspective,
Cartwright (2016) points out that shame arises along with the emergence of the self, in
the space between egocentric tendencies and sociocentric tendencies, and that this
shame becomes overwhelming when the integration of the two tendencies fails. Not
only is the loss of grandiosity at stake, but also a series of emotions (failure, weakness, dis-
grace, betrayal, abandonment, humiliation, and mortification) tied to feelings of insuffi-
ciency, deficiency, and devaluation in the eyes of others, putting the ego’s basic
qualities and existence into doubt (Bion 1992; Cartwright 2016). The ego, then,
becomes dependent on the gaze of the other, and is separated from its own internal
sources of support.
The ego/other dialectic and the difficulties with maintaining it operationally are
expressed differently depending on the patient’s level of mental functioning. At a
healthy level of psychological functioning, we find that there can be a predominance of
thin or thick skin without losing the balance between needs to appreciate oneself and
to be appreciated by others (and to appreciate them). This makes “win–win”games poss-
ible, in which an open sense of “we–go”(Emde 2009) arises. It is inevitable in these games
for narcissistic injuries to be had or inferred, but internal or interpersonal resources make it
possible to heal them. At neurotic levels of functioning, the balance between the self and
others is affected by a defensive rigidity in the face of unconscious conflicts, which leads to
dilemmas between self-affirmation at others’expense and seeking to please others at
one’s own expense. In the case of narcissistic disorders, these dilemmas lack dialectical
mediations, thus they become accentuated and it becomes difficult to find an equilibrium
between appreciation that comes from oneself and that that comes from others. This is
accompanied by a greater impact on mental functioning than in classic neurosis.
Finally, when the structural vulnerabilities typical of a borderline level of functioning are
at the forefront, both self-definition and relationships become problematic. The patient is
unable to regulate his or her self-appreciation, and sometimes even to care for him or
herself adequately. Relating is also compromised, and intimate relationships and
308 R. BERNARDI AND M. EIDLIN

empathy are not possible as, from one minute to next, others go from being perceived as
cold and distant to being seen as too close and invasive.
We would like to make one last comment about the therapeutic aspect. We have
seen that narcissistic phenomena include a range of feelings that go from devaluation
and shame to grandiosity and power over the other. Kohut emphasises the impor-
tance of empathic understanding for analysing narcissism. However, empathy is not
just sympathising with the patient. It is also, as Kernberg indicates, being able to
get closer to feelings that may upset or repel us, such as aggression or destructive-
ness, in order to understand them from inside the patient. Narcissism, whether
thin- or thick-skinned, brings into play our own capacity to empathise both with
grandiosity and with the fear of shame or humiliation. This type of patient often
brings us to feel we are in a minefield, where empathic failures can produce transfer-
ence storms or even jeopardise the treatment. Yet, we dare say that these explosive
zones are found, too, in our own countertransference, as we are exposed to feelings
within ourselves that are often conflicted. In this sense, understanding grandiose and
vulnerable aspects in ourselves, understanding our arrogance and our shame, as well
as the kind of relations that bring them together, can help us to analyse them better
in our patients.
Translations of summary
L’auteur de cet article explore deux formes ou aspects cliniques du narcissisme ainsi que leurs impli-
cations psychopathologiques : le narcissisme dit de la peau fine ou vulnérable (NV) et le narcissisme
de la peau épaisse ou grandiose (NG). Il passe en revue les différentes appellations qui sont en usage
et les caractéristiques qui servent à leur description. En prenant appui sur des vignettes cliniques qui
illustrent ces deux formes de narcissisme, il met l’accent sur leurs caractéristiques diagnostiques ; il
discute de leurs similitudes et différences tout en prenant en considération les facteurs qui peuvent
complexifier davantage encore la situation clinique. Il souligne l’importance de l’expérience de honte
et d’humiliation propre à ces états. A partir de ces comparaisons, il examine les mécanismes psycho-
dynamiques qui sont respectivement à l’œuvre dans ces deux cas de figure, y compris dans leur
rapport aux différents niveaux du fonctionnement psychique. L’auteur conclut son article en
faisant valoir que ces deux formes de narcissisme –NV et NG –signent un échec face aux difficultés
de l’articulation dialectique entre l’affirmation de soi et la reconnaissance de l’autre.
Dieser Beitrag untersucht zwei klinische Formen oder Aspekte des Narzissmus und ihre psycho-
pathologischen Implikationen: den dünnhäutigen oder vulnerablen Narzissmus (VN) und den dic-
khäutigen oder grandiosen Narzissmus (GN). Der Autor beleuchtet die unterschiedlichen
Bezeichnungen, die verwendet, und die Charakteristika, die beschrieben werden. Er untersucht kli-
nische Vignetten, die beide Typen des Narzissmus veranschaulichen, betont die je spezifischen diag-
nostischen Merkmale und diskutiert Ähnlichkeiten und Unterschiede sowie Faktoren, die dem
Behandlungsfall unter Umständen zusätzliche Komplexität verleihen. Unterstrichen wird die Bedeut-
samkeit von Scham und Demütigung. Auf der Grundlage dieser Vergleiche erfolgt eine Untersu-
chung der in beiden Fällen jeweils relevanten psychodynamischen Mechanismen und
insbesondere ihrer Beziehung zum psychischen Funktionsniveau. Der Autor zieht den Schluss,
dass sowohl VN als auch GN gescheiterte Strategien der Auseinandersetzung mit dem schwierigen
dialektischen Verhältnis von Selbstbehauptung und Anerkennung des Anderen darstellen.
Il presente lavoro esplora due forme o aspetti clinici del narcisismo insieme alle rispettive implica-
zioni psicopatologiche: il narcisismo chiamato “a pelle sottile,”o vulnerabile, e il narcisismo “a
pelle spessa,”o grandioso. Si passano anzitutto in rassegna i diversi nomi utilizzati per definirli e
le caratteristiche con le quali essi sono stati descritti; in seguito si esaminano alcune vignette cliniche
in cui figurano entrambi i tipi di narcisismo, mettendone in evidenza le caratteristiche diagnostiche e
INT J PSYCHOANAL 309

analizzandone oltre a ciò somiglianze e differenze, insieme ai fattori che possono rendere il quadro
clinico più complesso. Particolare rilievo viene dato all’importanza dei vissuti di vergogna e umilia-
zione. A partire da questa serie di confronti si esaminano poi i meccanismi psicodinamici coinvolti in
entrambe le situazioni, e in particolare la loro relazione con i diversi livelli di funzionamento mentale.
Si conclude infine che tanto il narcisismo “a pelle sottile”quanto il narcisismo “a pelle spessa”rap-
presentano strategie fallite per far fronte alla difficile articolazione dialettica tra autoaffermazione
e riconscimento dell’altro.
El trabajo explora dos formas o aspectos clínicos del narcisismo y sus implicaciones psicopatológicas:
el llamado narcisismo de piel fina (NPF) o vulnerable y el narcisismo de piel gruesa (NPG) o grand-
ioso. Se pasa revista a los diversos nombres utilizados y a las características con las que fueron descri-
tos. Se examinan ejemplos clínicos de ambos tipos de narcisismo destacando sus características
diagnósticas; y se analizan las similitudes y diferencias entre ellos y los factores que pueden dar com-
plejidad al cuadro clínico. Se destaca la importancia de las experiencias de vergüenza y humillación.
A partir de estas comparaciones se examinan los mecanismos psicodinámicos que están en juego en
ambos casos, en especial su relación con los niveles de funcionamiento mental. Se concluye que
tanto el NPF como el NPG constituyen formas fallidas de hacer frente a la difícil articulación dialéctica
entre la afirmación del self y el reconocimiento del otro.
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