 Dear colleagues, thank you for attending my presentation and welcome to the Psychiatry and Mental Health Conference 2019 in Dubai. Today I would like to discuss the confluence between narcissism, pathological narcissism and depression. Narcissism mourns the loss of narcissistic supply, attention. They grieve over vanished sources of supply. They bemoan the injustice and discrimination that they suffer at the hands of people they perceive as inferior. Narcissists are often in a bad mood, unhedonic, dysphoric, and outright depressed. The narcissist mood swings are self-destructive and self-defeating. Finally, at the end of my presentation, I will compare pathological narcissism with the manic phase of bipolar 1 disorder. Some scholars consider pathological narcissism to be indeed a form of depressiveness and this is the position of the authoritative magazine, Psychology Today for example. The life of the typical narcissist is indeed punctuated with the recurrent bouts of dysphoria, ubiquitous sadness and hopelessness, of unhedonium, loss of the ability to feel pleasure, and of clinical forms of depression, cyclothymic, dysthymic, or other. But this picture is obfuscated by the comorbidity of mood disorders with pathological narcissism. And so, we will have to tread lightly and subtly here. While the distinction between reactive, exogenous, and endogenous depression is obsolete, it is still, in my view, useful in the context of pathological narcissism. And that's because narcissists react with depression, not only to life crises, but also to fluctuations in narcissistic supply, in attention. And they also react with depression to a circumstantial inability to express their dominant psychosexual type, cerebral or somatic. The narcissist personality is disorganized. We all know that. It is precariously balanced. The narcissist regulates his sense of self-worth, not from within his ego, but from the outside by consuming narcissistic supply from other people. Any threat to the uninterrupted flow of attention of this supply compromises the narcissist's psychological integrity and his ability to function. It is perceived by the narcissist, actually, as life threatening. Indeed, depression can be conceptualized as a reaction to the systemic failure of either to trustworthy and efficacious coping strategies, either owing to a seismic change in circumstances and the environment or because of overwhelming new information. So let's start with the first type of depression, loss-induced dysphoria. This is the narcissist's depressive reaction to the loss of one or more sources of narcissistic supply, sources of attention. Or to the disintegration of a pathological narcissistic space, his stalking or hunting grounds, the social unit, whose members lavish him with praise and adulation and admiration. Another type of dysphoria is the deficiency-induced dysphoria. This is a deep and acute depression which follows the aforementioned loss of supply or pathological narcissistic space. Having mourned these losses, the narcissist now grieves their inevitable outcome, the absence or deficiency of narcissistic supply. Paradoxically, this dysphoria energizes the narcissist and moves him to find new sources of supply to replenish his dilapidated stalker. And this depression is the one that initiates what I call the narcissistic cycle. Then there is the self-worth dysregulation dysphoria. The narcissist reacts with depression to criticism or disagreement, especially from a trusted and low-term source of narcissistic supply. He fears the imminent loss of the source and the damage to his own fragile mental balance. The narcissist also resents his own vulnerability and his extreme dependence on feedback from others. And all these put together create a depressive reaction, which is therefore a mutation of self-directed aggression. Then there is the grandiosity-gap dysphoria. The narcissist firmly, though counterfactually, perceives himself as omnipotent, omniscient, omnipresent, brilliant, accomplished, perfect, irresistible, immune and invincible. This is the grandiosity construct. Any data to the contrary is usually filtered, altered or discarded altogether in an extreme form of confirmation bias or done in pruder effect. Still, sometimes reality intrudes. And then there's a grandiosity-gap. The narcissist is forced to face his own mortality, limitations, ignorance and relative inferiority. He sucks, he sinks into an incapacitating but short-lived dysphoria. And finally there's a self-punishing dysphoria. Deep inside, the narcissist hates and loathe himself. He doubts his own self-worth. That's why he needs input from the outside. He deplores his desperate addiction to narcissistic supply. The narcissist judges his actions and intentions harshly and sadistically via an inner critic or a superego that is out of control. The narcissist may be unaware of these dynamics, but they are at the heart of the narcissistic disorder. And the reason the narcissist hates to resort to narcissism is a defense mechanism in the first place. This inexhaustible will of ill-wish, ill-will, self-trust, trust-isement, self-doubt and self-directed aggression of hatred. This yields numerous self-defeating and self-destructive behaviors from reckless driving and substance abuse, from asqueuities, civil ideation, constant depression and so on and so forth. In this sense, narcissism, pathological narcissism, very much resembles borderline defenses. And indeed, when we diagnose borderline personality disorder, we put an emphasis on the narcissistic dimension. It is the narcissist's ability to confabulate, actually, that saves him from himself. His grandiose fantasies remove him from reality and prevent recurrent narcissistic injuries. Many narcissists end up being delusional, schizoid or paranoid. To avoid agonizing and knowing depression, they give up on life and the world itself. One therapeutic technique would be anchoring, reorienting the narcissist towards self-supply. Rather than resort to fickle and ephemeral external sources of narcissistic supply, the narcissist is taught and encouraged to resort to himself for the same good. To look forward with excited anticipation to the structured pursuit of hobbies, vocations, traits, skills and reward-eliciting behaviors. And this approach leverages the narcissist's grandiose solipsism and fantasy of omnipotence to render the narcissist emotionally self-sufficient in effect. There is no necessary connection between these two clinical conditions, depressive illness and pathological narcissism. In other words, there is no proven high correlation between narcissistic personality disorder or even a milder form of narcissism and enduring bouts of depression or major depressive episodes. Depression is a form of aggression. Transform, this aggression is directed at a depressed person rather than at his environment. This regime of repressed and mutated aggression is characteristic of both narcissism and depression and that's why sometimes the conference. See, narcissism is sometimes described as a form of low-intensity depression, as I mentioned. Originally, the narcissist experiences forbidden thoughts and urges sometimes to the point of an obsession or intrusive thoughts. His mind is full of this kind of mutations of aggression, curses, remnants of magical thinking, denigrating and malicious celebrations concerned with authority figures. Current, former, parents, teachers, bosses. And all this poisonous and toxic brew is all proscribed by the super ego or the conscience. It's forbidden. And this is doubly true if the individual possesses a sadistic, capricious super ego, a result of their own kind of parenting by narcissistic parents. These thoughts, these wishes, do not fully surface as fraudulums that they are repressed. The individual is only aware of them in passing and vaguely. But they are sufficient to provoke intense guilt feelings and to set in motion a chain of self-flagellation and self-punishment. Amplified by an abnormally strict, sadistic and punitive conscience of super ego, these kind of celebrations result in a constant feeling of an imminent, innate threat. This is what we call anxiety. It has no discernible external triggers and therefore it is not fear. It is the echo of a battle between one part of a personality which viciously wishes to destroy the individual through excessive punishment and his or her instinct for self-preservation and survival. Anxiety is not, as some scholars have it, it's not necessarily a rational reaction to internal dynamics involving imaginary threats. Actually, anxiety is more rational than many fears. The powers unleashed by inner constructs such as the super ego are so enormous. The intentions are so lethal. The self-loathing and certain degradation that it brings with it are so intense that I consider the threat to be very real. Overly strict super egos are usually coupled with weaknesses and vulnerabilities in all other dimensions of the personality. Thus, there is no psychological structure which is capable of fighting back of taking the side of the depressed person. It is small wonder that depressives have constant suicidal ideation. They toy with ideas of self-mutilation and suicide or worse, they commit suicide in order to avoid this capable battle. Confronted with such a horrible internal enemy, lacking in defenses, falling apart at the seams, depleted by previous attacks, devoid of energy of life, depressed people wish to die. Their anxiety is about survival. The alternative is being usually self-tomant and self-admiration. Depression is how this kind of patient experiences is of a flowing reservoir of aggression. He is a volcano which is about to erupt and bury him under his own ashes. Anxiety is how he experiences the war raging inside him, his inner conflict. Sadness is a name that he assigns to the resulting wariness. To the knowledge of the battle is lost and personal doom is at hand. Disintegration, decompensation and acting out. Depression is the acknowledgement by the depressed individual that something is so fundamentally wrong there is no way he can win. The individual is depressed because he is fatalistic. As long as he believes that there is a chance, however slim, to better his position, he moves in and out of depressive episodes. True, anxiety disorders and depression mood disorders do not belong in the same diagnostic category but they are very often comorbid. In many cases the patient tries to exercise his depressive demons by adopting ever more bizarre rituals or obsessive compulsion or obsessive compulsion kicks in. These are the compulsions which by delivering energy and diverting energy and attention away from the bed content is more or less symbolic or ritualistic and arbitrary. These compulsions bring temporary relief and an easing of the anxiety. It is very common to meet all four. A mood disorder, an anxiety disorder, an obsessive compulsive disorder and a personality disorder in one patient as all of us know. Depression is the most varied of all personal illnesses. It assumes myriad guises and disguises. Many people are chronically depressed without even knowing it corresponding cognitive or affective content. Some depressive episodes are part of a cycle of ups and downs like in bipolar disorder or in milder form in cyclotinic disorder or in narcissism. Other forms of depression are built into the characters and personalities of the patients. For example, dystemic disorder or what used to be known as depressive neurosis. One type of depression is even seasonal that can be cured by phototherapy, gradual exposure to paraphernal time, artificial lighting. The numerous forms, we all experience adjustment disorders with depressed mood used to be called reactive depression which occurs after a stressful life event or as a direct, entirely limited reaction to it. These poisoned, garden varieties are all pervasive. Not a single aspect of human condition escapes them. Not one element of human behaviour avoids their grief. It is not wise and has no predictive or explanatory value to differentiate good or normal classes of depression from pathological ones. They are not good depressions whether provoked by dysfunction or endogenously from the inside. Whether during childhood or later in life. All depressions are one and the same. A depression is a depression is a depression no matter what its precipitating causes are or which stage in life it occurs. The only valid distinction seems to be phenomenological. Some depressive patients slow down psychomotor retardation, the appetite, the sex life, libido and sleep all of them alter. This is known as vegetative function disorder. All of them are notably deterred. Behaviour patterns change or disappear altogether and these patients feel dead. They are unhedonic. They find pleasure in excitement in nothing and they are also dysphoric, they are sad. The other type of depressive person is psychomotorically active and at times hyperactive. These are the patients that I described above. They report overwhelming guilt feelings, anxiety even to the point of having delusions delusional thinking, not grounded in reality but in a thought and logic of our outlandish world. The most severe cases and severity is also manifested physiologically in the worsening of the above mentioned symptoms. The most severe cases exhibit paranoia to secretary delusions involving them in systematic conspiracies. They are, they seriously entertain ideas of self-destruction and the destruction of others. These are nihilistic delusions. They hallucinate. Their hallucinations reveal their hidden content, self-deprecation. They need to be punished, humiliated, bad or cruel or permissive thoughts about authority figures and so on. So depressive, depressive is almost never psychotic. Psychotic depression does not belong to this family, in my view. Depression does not necessarily entail a marked change in mood. Mass depression is therefore difficult to diagnose if we stick to the strict definition of depression as a mood disorder. Depression can happen at any age. It can happen to anyone. Whether without a preceding stressor, stressful event, its onset can be gradual, its onset can be dramatic. The earlier in life depression occurs, the more likely it is to recur. And this apparently arbitrary and shifting nature of depression only enhances the guilt feelings of the patient. He refuses to accept that the source of his problems is beyond his control. At least as far as his aggression is concerned. He doesn't worry about biochemical, neuro-transmitters or genetic factors. The depressive patient believes himself or events in his immediate past of his environment. And this is a vicious and self-fulfilling prophetic cycle. The depressive feels worthless, doubts his future and his abilities feels guilty. This constant brooding alienates his nearest and dearest of course. And his interpersonal relationships become dysfunctional. And this in turn exacerbates his depression and so on and so forth. The patient finally finds it most conveniently rewarding to avoid social interactions altogether to go skizz it. He resigns from his job, shies away from social occasions, sexually abstains and shuts out his few remaining friends and family members. Or stillity, avoidance, histrionics, all emerge and the existence of personality disorders only makes matters worse. Freud said that the depressive person has lost a loved object, was deprived of a properly functioning parent. The psychic trauma suffered early on can be alleviated only by inflicting self-punishment. Thus implicitly penalizing and devaluing the internalized version of the disappointing love object. The development of the ego, said Freud, is conditioned upon a successful resolution of the loss of the loved objects. A phase all of us have to go through. When the love object fails, the child is furious, revengeful and aggressive, unable to direct these negative emotions of the frustrating parent, the child directs them at himself instead. It's a proto-type of depression. Narcissistic education means that the child prefers to love himself, direct his limit with himself, then to love an unpredictable, abandoning parent, mother in most cases. Thus, the child becomes his own parent and directs his aggression at himself, at the parent that he had become. Throughout this wrenching process, the ego feels helpless and this is another major source of depression. When depressed, the patient becomes an artist of sorts. He tires his life, paper around him, his experiences, places and memories, with a thick brush of schmaltzy, sentimental and nostalgic longing. The depressive imbues everything with sadness, attuning, aside a color, another person, situation or memory. He is triggered and in this sense, depression is a kind of post-traumatic condition. The depressive is cognitively distorted, interprets his experiences, evaluates himself and assesses the future, totally catastrophically and negatively. He behaves as though constantly disenchanted disillusioned, inverting, a dysphoric effect. And this helps to sustain the distorted perceptions. No success, no accomplishment, no support can break through this cycle because it is so self-contained and so self-sustaining and self-enhancing. Dysphoric effect supports distorted perceptions which enhance dysphoria, which encourages self-defeating behaviors which brings about failure and which justifies depression, of course. And this is a cozy little circle charmed and emotionally protective because it is unfailingly predictable. Depression is addictive because it is a strong love-substitute. Much like drugs, it has its own rituals, language and worldview. It imposes rigid order and behavior patterns of the depressive. And this is learned helplessness. The depressive prefers to avoid even situations which are the promise of improvement in his to his harrowing condition. The depressive patient has been conditioned by repeated aversive stimuli. To freeze in his tracks, he doesn't even possess the requisite energy to end his cruel predicament by committing suicide. The depressive is devoid of the positive reinforcement which are the building blocks of our self-esteem. He is filled with negative thinking about himself, about his goals, or lack of them, about his lack of achievements, his emptiness, his loneliness and so on and so forth. And because his cognition and perceptions are deformed, no cognitive or rational input can alter the situation. Everything is immediately reinterpreted to fit the paradigm. People often mistake depression for emotion. They say about the narcissist but he is sad and they mean but he is human, but he has emotions. And this is wrong. It's true that depression is a big component in the narcissist's emotional makeup but it mostly has to do with the absence of narcissistic supply. It mostly has to do with nostalgia for more plentiful dates full of adoration and attention and applause. It mostly occurs after the narcissist has depleted his secondary source of narcissistic supply. His spouse is made, girlfriend, colleagues with his constant demands for the reenactment of his days of glory. Some narcissists even cry but they cry exclusively for themselves and for the lost paradise. They do so conspicuously, ostentatiously and publicly in order to reignite the narcissistic cycle in order to attract attention in a thing. The narcissist is a human pendulum hanging by the thread of the void that is his false self. He sweeps from brutal and vicious abrasiveness to malicious, modeling and saccharine sentimentality. It is only a simulacrum, a very similigant, a facsimile or a confabulation enough to fool the casual observer enough to extract the narcissistic drug of the people's attention, the reflection that somehow sustains his house of cards. But the stronger and more rigid the defenses and nothing is more resilient than pathological narcissism, believe me, the stronger the defenses, the greater and deeper the birds the narcissist aims to counteract or compensate for. One's narcissism stands in direct reaction to the seething abyss and devouring vacuum that one harbors the true self. Perhaps narcissism is indeed, as many people say, a reversible choice but it is also a rational choice guaranteeing self-preservation and survival. It's an adaptation. The paradox is that being a self-loading narcissist may be the only act of true self-love that the narcissist ever commits. Now let us study a specific mood disorder and compare it to narcissism. Bipolar One Disorder The manic phase is often misdiagnosed as narcissistic personality disorder. Bipolar parent patients in the manic phase exhibit many of the signs and symptoms of pathological narcissism, hyperactivity, self-centeredness, lack of empathy and control frequently. During this recurring chapter of the disease the patient is euphoric, has grandiose fantasies, spins, unrealistic skins and has frequent rage attacks is irritable if her or his wishes and plans are inevitably frustrated. The manic phases of the bipolar disorder, however, are limited in time. Of course, narcissistic personality disorder is not. Furthermore, the mania is followed by usually protracted, depressive episode. The narcissist is also frequently dysphoric, but whereas the bipolar sinks into deep self-deprecation, self-devaluation, unbounded pessimism, all-pervasive guilt and anhedonia, the narcissist, even when depressed, never forgo his narcissism, his grandiosity sense of entitlement, haughtiness and lack of empathy. Narcissistic dysphoria are much shorter, they are utterly reactive, they constitute a response to the grandiosity gap. In plain words, the narcissist is dejected when confronted with the abyss between his inflated self-image and grandiose fantasies and the drab reality of his life, his failures, lack of accomplishments, disintegrating personal relationships and low status. Yet one dose of narcissistic supply is enough to elevate the narcissists from the depth of misery to the euphoric heights of mania. And it is not so with the bipolar. The source of her or his mood swings is assumed to be brain biochemistry, not the availability of narcissistic supply. Whereas the narcissists is in full control of his faculties even when maximally agitated the bipolar often feels that he or she lost control of his or her brain and this is the flight of ideas. She feels that speech, attention span are out of control, destructibility and that motor functions are out of control. This is never the case with the narcissists. The bipolar is thrown to reckless behaviors and to substance abuse only during the manic phase. The narcissist does drugs, drinks, gambles shops of credit, indulges in unsafe sex or other composite behaviors both when he is elated and when he is deflated. As a rule the bipolar's manic phase interferes with his or her social and occupational function. Many narcissists in contrast reach the highest ranks of their community church firm or voluntary organizations. Most of the time they function flawlessly. Though the inevitable blow ups, the great extortion of narcissistic supply usually put an end to the narcissist's career and social reasons. But still most narcissists are high functioning. The manic phase of bipolar sometimes requires hospitalization and more frequently than admitted involves psychotic features. Narcissists are never hospitalized as the risk of self harm is minute. Moreover psychotic micro-episodes in narcissism are decompensatory in nature and appear only under unendurable stress for example in intensive therapy. The bipolar's mania provokes discomfort in both strangers and in the patients nearest and nearest. His constant sheer and compulsive insistence on interpersonal sexual and occupational or professional interactions these engender unease and repulsion. His bipolar's ability of mood, rapid shifts between uncontrollable rage and unnatural good spirits it's done right intimidating something wrong and privy. The narcissist's gregariousness by comparison is calculated. It's called, it's controlled, it's goal-oriented the extraction of narcissistic supply. It's a bit psychopathic. The narcissist's cycles of mood and effect are far less pronounced and a lot less rapid. Bipolar's cycle, narcissists rarely saw. The bipolar's swollen self-esteem, overstated self-confidence, obvious grandiosity and delusional fantasies are akin to the narcissists. That's also the diagnostic confusion of us. Both types of patients purport to give advice carry out an assignment to accomplish a mission or embark on an enterprise for which they are uniquely unqualified and lack the talents, his knowledge or experience required. But the bipolar's bombast is far more delusional than the narcissists. Ideas of reference, referential ideation, magical thinking are common and in this sense the bipolar is closer to this case of people than to the narcissistic. There are other differentiating symptoms. Start with sleep disorders, notably acute insomnia. These are common in the manic phase of bipolar and are common in narcissism. So is manic speech, pressured, uninterruptible, loud, rapid, dramatic speech including singing and humorous sides. Sometimes incomprehensible incoherent, chaotic and it lasts for hours. It reflects the bipolar's inner turmoil and his and her inability to control her racing kaleidoscoping thoughts. As opposed to narcissists, bipolar in the manic phase are often distracted by the slightest stimuli are unable to focus on relevant data or to maintain the thread of conversation. They are all over the place, simultaneously initiating numerous business ventures joining myriad organizations writing up thing letters contacting hundreds of friends and friends of strangers acting in a domineering, demanding and intrusive manner totally disregarding the needs and emotions of the unfortunate recipients of their unwanted attentions. They rarely follow up of their approaches. The transformation is so marked that the bipolar is often described by her closest as not himself, not herself. Indeed some bipolar's advocate change name and appearance and use contact with their former lives. Antisocial or even criminal behavior is not uncommon and aggression is marked, directed at both others in terms of a soul and oneself in terms of suicide. Some bipolar's describe an acuteness of the senses akin to experiencing experiences recounted by drug users. They describe smells, sounds and sights as accentuated and attain an unearthly quality synesthesia. As opposed to narcissists, bipolar's regret them with deeds following the manic phase. They try to atone for their actions. They realize and accept that something is wrong with them and they seek help. During the depressive phase they are ego-distonic and their defenses are autoplastic. They blame themselves for their defeats, failures and mishaps. Exactly the opposite is with narcissists. And finally, pathological narcissism is already discernible in early adolescence. The full-fledged bipolar disorder, including the manic phase, rarely occurs before the age of 20. The narcissist is consistent in his pathology, not so the bipolar. The onset of the manic episode is fast and furious and results in a conspicuous metamorphosis of the patient. Thank you for listening.