I live in L.A. "Hollywood" is all around me. Beautiful women are drawn to this city like moths to a flame, and then spend their lives struggling to maintain the artifice of the ideal physique. These efforts show up with an identifiable "look", the stretched, puffed, smoothed, distorted faces that betray the marks of the plastic surgeon and the traces of Botox and Restylane. Watching the octuplets' mother on TV this week, I had the same vision. A young woman with attractive features that hinted of the effects of cosmetic enhancement. It was, honestly, a jarring image. As a doctor, I can testify that most new mothers have a radiant glow that overcomes the obvious exhaustion and relief following the rigors of pregnancy and natural or surgical childbirth. Few of them, however, have a "camera-ready" presence that includes make-up and sound bites. Ms. Suleman's accounts speak for themselves. She self-describes her dysfunctional childhood, her bouts of depression, her desire to fill the emptiness in her heart with her love for all "her children", her illusion that she will be able to care for 14 children, age 7 and under, some with likely special needs, alone. As Ms. Suleman is not my patient, it would be inappropriate for me to speculate or diagnose any psychological pathology from the distance of my computer or TV screen. However, I thought I might share some general thoughts on psychiatric conditions that would be interesting for our readers. Most readers are probably familiar with the signs and symptoms of depression-but may not be as familiar with another diagnosis, narcissistic personality disorder (NPD).
The Diagnostic and Statistical Manual describes NPD as "a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has a grandiose sense of self-importance 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love 3. Believes that he or she is "special" and unique 4. Requires excessive admiration 5. Has a sense of entitlement 6. Is interpersonally exploitative 7. Lacks empathy 8. Is often envious of others or believes others are envious of him or her 9. Shows arrogant, haughty behaviors or attitudes
Some factors identified in the development of NPD include:
1. An oversensitive temperament at birth 2. Overindulgence and overvaluation by parents 3. Valued by parents as a means to regulate their own self-esteem 4. Excessive admiration that is never balanced with realistic feedback 5. Unpredictable or unreliable caregiving from parents 6. Severe emotional abuse in childhood 7. Being praised for perceived exceptional looks or talents by adults 8. Excessive praise for good behaviors or excessive criticism for poor behaviors in childhood
Narcissistic parents often beget narcissistic children. A mother who is seeking nurturing and validation from her infant may trigger the development of NPD, as can a detached, unempathetic, or self-absorbed parent. The child grows up with a sense of being flawed, unlovable, unimportant, unconnected. Ashamed, the child unconsciously responds to this real and feared rejection and isolation by over-compensating and manifesting over-confident, grandiose behavior. The adult with NPD endeavors to control others in an attempt to protect this "unlovable" hidden self and is often unable to see others as fellow humans and to be tolerant, kind, empathetic, and aware of other's needs. A person with NPD often finds it difficult to deal with setbacks, criticism, or disagreements-these individuals may react with an explosive narcissistic rage, challenging professional and personal relationships.
When the NPD adult has children of his or her own, he or she is likely to see the children as extensions of him or herself rather than as separate and unique individuals. A parent may make demands of the children to provide for the parent's emotional needs, and to reject or neglect the child if these needs are not met. The children may face significant emotional and even physical abuse, a withdrawal of love and affection, and inappropriate criticism. The result is often a propagation of the seeds of narcissism in the next generation.
Because people with NPD are often charming, articulate, and capable, and have little insight into their psychopathology, they are often unlikely to seek therapy themselves, or be identified as needing treatment by others who have not approached them intensively with an aim towards diagnosis. Plastic surgeons, for example, do often screen for psychopathology before considering requested operations-someone who seeks a face lift or breast implants to fulfill a psychological emptiness, for example, may find the surgery does not address the underlying need and may be greatly unhappy with the results. It is critically important for physicians to be able to identify underlying mental health issues before engaging in invasive or irreversible procedures.
Regarding Ms. Suleman, and the reality of the challenges she and her family will be facing, all I can say is I wish her all the best. I even more wish the best for her children as well--nurturing rather than needy parenting, giving rather than selfish love, support services for any identified special needs, and an adequate standard of living that includes sufficient food, medical care, schooling, and safety. With contributions (and consultations) from California social service programs, Ms. Suleman's children may find the path to adulthood less challenging than so many of us fear. However, I must wonder, if, on the road to adulthood, these children too may struggle with the sense of abandonment that Ms. Suleman described from her own childhood. Narcissism wreaks its damage from generation to generation-the cycle continues.