Features, State and Context of Narcissism in Drug Misuse

Abstract

Both clinical and street-based encounters with people who misuse drugs have led the authors to examine the relationship between misuse of drugs and narcissism. Widely accepted criteria for diagnosing Substance Use Disorder (SUD) suggest parallels between narcissistic traits (e.g. invulnerability to consequences and lack of empathy for others) and the characteristics of drug abusers. Because narcissism as a concept has a long and somewhat confusing history, we first reviewed its origins in the psychoanalytic tradition of psychiatry and its exegesis into current clinical concepts in order to arrive at a set of attributes that may be useful when applied to problems of drug abuse. This process required extensive review of the literature on narcissism and its interactions with the literature on drug abuse. This process led to an understanding that positive self-concept may exemplify a variety of socially beneficial narcissism, but that at the other end of narcissism’s continuum of traits may be found exploitative and non-empathetic traits. Furthermore, the negative traits of narcissism, as they may arise in adolescence along with drug use, can support an individual’s ongoing dependence on drugs, especially if narcissism and drug use persist into adulthood. Our investigation of narcissism and drug use revealed, through in-depth interviewing, that some drug users employ drugs and alcohol to feed their self-concepts of superiority over other people. Our findings suggest that treatment for drug abuse cannot proceed assuming that drug users have low self-concepts. Rather, their continued use of drugs may emanate from a narcissistic sense of superiority.

Keywords:

• Narcissism
• psychopathy
• empathy
• invulnerability
• drug misuse

Introduction

The multifactorial character of the consumption and misuse of drugs

One basic aspect of the use and misuse of drugs is its heterogeneity. Likewise, there is no answer to the question of what causes or sustains what the field has come to call “substance use disorders” (SUDs). When we address SUDs, we are dealing with multifactorial questions that vary widely according to the type of drug, the user, and the context of use. The developing course of drug use disorders includes a wide range of variation in duration, quantity of consumption, and types of consumption over time (Jackson et al., 2005), tending to increase progressively in adolescence and early adulthood and diminishing in later adulthood.

Psychoactive drugs cause neurochemical changes, and a growing number of studies signal the importance of genetic factors in the risk of developing SUDs (Kendler et al., 2003). Genetic factors have been found to be associated with risk of SUDs more than the mere presence of drug use, and it is understood that the risk of SUDs is a consequence of the combination of, and interaction among genetic factors, environment, and individual risk behaviors (Kendler et al., 2003). Multiple explanatory models exist for the initiation of drug consumption and maintenance of use patterns, featuring among others, the illness model, the social learning model, the psychoanalytic model, the family model, and ethnographic or cultural model. In some of these models, SUDs would be the practical consequence, a logical behavior that reflects an attempt to achieve emotional self-regulation. In others, drug use is the product of the seeking of sensations with recreational intent, or as the result of some predisposition.

As motivations for drug use, there have been various typologies that imply individual objectives such as the potentiation of positive animus or social objectives such as to foment social relations with friends, or to face other people (Cooper et al., 1992, Cooper, 1994). In general, the integrative models of SUDs consider that once initiated, consumption is maintained through biochemical action, changes in self-perception, defense mechanisms, conditioning and learning, psychopathology, as well as cultural, social, and family factors. These processes would be multiple, and their impact would vary from one individual to the other. Nevertheless, once the disorder is established, it would convert to primary, with its own suite of symptoms and a defined progression. The different models of drug use disorder lead to an understanding of these disorders as a complex phenomenon in which genetic factors, biographies, and social and cultural factors interact. The principal actions of treatment, however, are based on psychosocial concepts, including medically oriented programs of treatment and intervention. In fact, basic and common aspects of treatment response include motivation, duration of treatment, the experience of the professional, the development of confrontation and adaptation, as well as the therapeutic relationship (Moos, 2003; Tetzlaff et al., 2005).

Motivation, invulnerability, and lack of empathy in the criteria for diagnosing substance use disorders

The American Psychiatric Association (2013) states that the diagnosis of SUD requires, among other criteria, repeated consumption of drugs with the result of abandoning major role obligations in work, school, or home (criterion 5), continuing substance abuse despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (criterion 6) and recurrent substance use in situations in which it is physically hazardous (criterion 8). In these criteria, two common characteristics are manifest in drug use disorders: (a) lack of motivation to slow or stop consumption when that consumption causes suffering in family or loved ones, and (b) denial of danger to one’s person in various versions, including legal complications and health. Although they are not generalizable to all cases, these characteristics are notably frequent.

How the motive for the consumption of a drug becomes more powerful than the motive for protecting one’s family or oneself is still ill understood. Some have tried to explain these characteristics through the reinforcing properties of the drugs, specifically, the dopaminergic effect, indicating that the reinforcing effect could acquire such magnitude that it would substitute for the importance of affective needs, economics, and health. Nevertheless, this hypothesis, even though somewhat true, does not completely explain the differences in degrees of motivation for the control of drug consumption in drug use disorders.

The classic model for behavior change posited by Prochaska and DiClemente (1984) describes a first stage when the potential patient is contemplating the possibility of ending drug use (or any other risky behavior), and a second stage in which he/she considers stopping, but has not yet decided to do so. Into these stages come key factors such as the minimization or denial of risk, perception of invulnerability, or the absence of empathy for the suffering of loved ones. These implicit characteristics of drug abuse, since they consist at least in part of egocentrism and scarce empathy, together with the sense of invulnerability, are typical of pathological narcissism. Thus, it is worth noting that this personality trait needs further consideration as a factor that predisposes, precipitates, and maintains drug use disorders.

If we find a sense of invulnerability and absence of empathy to be implicit in the diagnostic criteria of Substance Use Disorders (SUDs), we can infer that the development of narcissistic traits can be a direct consequence of a change in personality originating with the consumption of drugs as it is considered in the DSM-5 (American Psychiatric Association, 2013). Without obviating this possibility, in this work we posit a process of dynamic interaction, in which lack of empathy, egocentrism, minimization of danger, denial, and the sense of invulnerability may also be part of a suite of predisposing and maintaining factors for drug abuse.

We tend to associate narcissism with a stereotypical person who has attractive physical attributes, high position, and social success. These attributes, with some exceptions, are not associated with drug use in the usual profile of the drug abuse disorder. Nevertheless, recent studies of narcissism and concretely the delimitation of its different types, reveal a gamut of variety that helps identify this characteristic in profiles of subjects with drug abuse disorders that frequently are not associated with the concept of narcissism other than in very specialized patterns.

Objectives

It is not our goal to try to review the causes of addiction and drug abuse, nor elaborate a theory on those causes. In the present article, we briefly review the concept of narcissism, its typology, and the possible implications for patterns of drug use, especially its role as a factor in the initiation of consumption. We also explore narcissism as a factor in maintaining consumption patterns. We suggest the importance of considering narcissism as an attribute of personality, as state, and as cultural context. This view of narcissism can help in understanding the individual user’s minimization of perceived risk related to health, overestimation of invulnerability, and lack of empathy toward the suffering of others, patterns that seem to constitute a parallel between drug use disorders and narcissism.

Narcissism as feature

Definition and types

Because the references in the literature on narcissism to date have been predominantly psychoanalytic (see Freud, 1957), the use of specialized terms of little precision, such as “narcissist perversion,” “narcissist regression,” ”primary narcissism,” or “narcissistic personality” has fomented usage that tends not to extend beyond the space occupied by psychoanalysis. Inconsistencies and important methodological evasions also have contributed to this usage (Auerbach et al., 1993) which varies and makes understanding narcissism as a psychological construct difficult. These usages treat narcissism variously as a personality trait, as a vulnerability factor for other psychological disorders or as a personality disorder in the sense of psychiatric illness. Frequently, these forms are not sufficiently delimited to differentiate them from other related terms, such as “self-esteem” and “egocentrism.”

Defined broadly, narcissism is an intense psychological interest in oneself. In other words, it is the mental occupation with one’s own self. In this sense, everyone is narcissistic to some degree, and little can be gained in comprehension that associates narcissism with pathology and identifies it with egotism.

Among the formulations of narcissism in the literature, Kohut (1966, 1971) contributed the concept of arrogant narcissism, Morf and Rhodewalt (2001a, 2001b) understand narcissism in terms of social relations. Baumeister and Vohs (2001) conceive of narcissism as a pattern of addiction to self-esteem. Ronningstam (2005) establishes a typology of narcissism, understanding it as a continuous dimension that ranges from healthy narcissism to pathological narcissism.

Narcissism and self-esteem

Although some authors consider narcissism to be an exaggerated form of self-esteem, one facet of self-esteem, or an unstable and contingent form of self-esteem (Campbell et al., 2002; Kirkpatrick et al., 2002; Morf & Rhodewalt, 2001a, 2001b; Tracy & Robins, 2003; 2006), it is possible to establish a clear distinction between narcissism and a positive and healthy vision of oneself.

In a broad sense, narcissism refers to a vision of oneself, personal development, self-regulation, and the development of interpersonal relations. Healthy narcissism would be useful for the individual to face challenges, overcome defeats and unexpected adverse events, to be creative, to love, as well as to experience satisfaction and triumph. Narcissism colors the relation with oneself and with others, the perceptions of the sense of life, and the significance of personal work (Wink, 1991).

Adolescence, a phase characterized by egocentrism and self-definition, is a period in which drug use usually is initiated (Johnston et al., 1999). After onset, use increases progressively, eventuating in the development of Substance Use Disorder, arriving at a peak at the beginning of adulthood (age 18–25), when parental supervision diminishes and continuing between 22 and 32 years of age, with the entry into matrimony and parenthood. That is, increment in the abuse of drugs is associated with individuation and autonomy of adulthood, while the diminution of drug abuse is related to the acquisition of the adult role (Bachman et al., 1997). In this sense, a subgroup of adolescents has been described with problematic conduct characterized by early consumption of drugs and symptoms of externalization with the early onset of consumption, and that they escalate rapidly to problematic levels of abuse and drug dependence (Zucker et al., 1994, Chassin et al., 2002). Elkind’s Elkind (1967) theory of adolescent egocentrism describes adolescence as a period characterized by the perception of invulnerability to risk or danger, related to the tendency of the adolescent to see him/herself as unique. Egocentrism, that term that narcissism expresses, fits perfectly with individualist culture, especially with individualist expression.

The Theory of Reputation Management (Emler, 1984, 1990) posits that delinquency and illegal behavior can be the result of positive choice. The place of delinquent activity is the group of friends or similar people. This placement implies that delinquent or illegal activities bring about inclusion. For those who cannot acquire a conventional reputation, the initiation and maintenance of a delinquent or illegal reputation requires reference to standards and valorizations of the members of the group. In adolescence the consumption of alcohol, nicotine, and other drugs begins. Although the theory of reputation has not been applied extensively to the use of drugs, it appears plausible that the use of illegal drugs may be a route toward establishing credentials in a chosen group. For these authors, the individuals with low self-control are those who select environments, relations, and people who lead in the direction of deviance.

Covert narcissism

In the case of Covert Narcissism, the patient is hypervigilant or shamed (Hendin & Cheek, 1997; Wink, 1991). This condition implies vulnerable self-esteem, feelings of shame, sensitivity to humiliation, sense of emptiness, disdain in response to criticism or defeat and personal disaster, difficulty in tolerating criticism, inhibition, along with apparent modesty and disinterest in social success. The lack of maintained commitment, the difficulty in empathizing and feelings of envy, covert narcissism includes shame, hypersensitivity to humiliation, elevated self-criticism, and vocational inhibition.

The continuum of narcissism

It is possible to understand narcissism within a continuous dimension, where one pole would have healthy narcissism conjoined with healthy self-esteem, necessary for good self-confidence, and another pole where elevated levels would indicate arrogance and interpersonal exploitation with grandiose psychopathy. One could say that narcissists are different from the rest only in degree, not in type, through their extreme preoccupation with themselves. Between these two poles, one would encounter narcissism that is neither psychopathic, ostentatious nor covert, whose interpersonal exploitation is not calculated nor cruel but rather insensitive and forgetful. The psychopath tries to victimize others, while the narcissist exploits others due to his/her incapacity to conceive of others as people who deserve consideration. Psychopathic aggression is based on an open indifference to the pain inflicted on other persons due to a self-vision in which others are devalued, while the forgetful narcissist is simply inconsiderate and insensitive without the intentionality of psychopathic aggression.

Narcissistic and antisocial personality disorders

The DSM-III and DSM-IV included the diagnostic category called narcissistic personality disorder (American Psychiatric Association, 1980, 1994). Its discriminatory validity, however, was thin and had little temporal stability (Cain, Pincus, & Ansel, 2008). Epidemiological studies noted that narcissistic personality disorder (NPD) was more frequent in young adults than in any other group. Stinson et al. (2008), in a study of a sample of 34,653 participants found that NPD was a less stable condition than had been previously assumed. This survey found NPD to be prevalent in the general population (6.2%), with more elevated rates among men (7.7%) than among women (4.8%), as well as higher in prevalence in African American men and women, Hispanic women, young adults, divorced or separated persons, with an association with abuse of alcohol and alcohol dependence.

These studies also found that NPD reduced with age due to the challenges in the transition from adolescence to adulthood and was more associated with dysfunction in males than in females (Stinson et al., 2008). Because of these findings a debate arose over including this diagnostic category in the DSM-5 (American Psychiatric Association, 2013). Possibly due to an emphasis on grandiosity and scarce emphasis on narcissistic vulnerability and narcissistic hypersensitivity associated with the emotional dysregulation (Pincus & Lukowitsky, 2010), the diagnosis of NPD in the DSM-III and DSM-IV presented shortcomings that limited its utility. Nevertheless, the same diagnoses are included in the DSM-5 (American Psychiatric Association, 2013) promoting a strategy that emphasizes assessment of impairments in self-regulation and emotion regulation in a collaborative process of diagnosis between patient and clinician. Further studies will clarify whether these changes have corrected DSM-III and DSM-IV limitations.

In the clinical field, the association between NPD and substance use has been recently acknowledged in the differential diagnosis of the DSM-5, where it asserts that NPD should “also be distinguished from symptoms that may develop in association with persistent substance abuse” (American Psychiatric Association, 2013). Unfortunately, the DSM-5 neither specifies the method nor the specific criteria that need to be differentiated.

Cultural values and narcissism: narcissistic individualism and collective narcissism

The personal characteristics of each person develop in relation to the cultural space in which each person lives (Markus et al., 1996). One important mode of classifying cultural spaces is the dimension called individualism/collectivism (Triandis, 1995). Collectivism is a pattern of social relations in which persons are highly involved with each other and feel included in one or more collectives. Their conduct is guided by the norms and obligations of the collectives. They situate the achievement of collective goals above personal goals. In contrast, individualism is a pattern of social relations in which the participants are related to each other in a mode. Given that the members of individualist cultures tend to center on themselves, they logically develop more narcissistic traits than the members of collective cultures (Foster et al., 2003).

Generational differences can be construed as cultural differences, and the measures by which youth are socialized with new and different values change over time. Twenge (2006) has posited a period in United States society as a time of enhancing the self-concept of children. According to Twenge and Campbell (2010), this trend has fomented narcissism and egotism instead of fomenting self-esteem.

For decades the psychological literature has affirmed the increment in narcissistic aspects among late adolescents and early adults in our society (Lasch, 1979; Twenge, 2006; Twenge et al., 2008, 2012; Twenge & Campbell, 2010). These investigators studied the evolution of narcissism over the last 40 years, analyzing the scores of the Narcissistic Personality Inventory of a sample of 49,818 participants in 38 university campuses as well as the scores of 4152 participants in one university campus to eliminate the possible confound related to campus. The authors showed that the scores had risen progressively between 1994 and 2009, indicating a significant increment of narcissistic attributes in North American students across different generations. The results of this study are consonant with the study conducted by Stinson et al. (2008) who described a cohort effect in the actual differences in lifetime prevalence of Narcissistic Personality Disorders (NPD) at 3.2 for people over 65, 5.6 for those 45 to 64, and 7.1 for respondents 30 to 44, and 9.4 for those between 20 and 29. In a cultural context where individualism receives emphasis, a high prevalence of narcissistic characteristics is not surprising.

Traits, states and narcissist contexts as risk factors in the use of drugs

Self-esteem, narcissism, and drug use

The relation between self-esteem and drug abuse has yielded controversial results, as some authors have reported that low self-esteem or high self-esteem can be a risk factor or a protective factor for drug use while other authors find no relation (Jessor et al., 1991; McBride et al., 1991; Thompson, 1989; Schroeder et al. 1993). Thus, it has been reported that self-esteem would be related to consumption of alcohol and illegal drugs in adolescence (Kavas, 2009). In a sample of adolescents in secondary school, (Donnelly et al., 2008) found that self-esteem measured in a general way showed little relation with drug use, with more importance in consideration of specific areas of self-esteem. Concretely, elevated self-esteem related to home or academic performance presented a protective character, while self-esteem related to peers was related in an ambivalent way, with drug use acting as a protective factor or a risk factor, depending on the type of other delinquent conduct. In consonance with these results, in a sample of 1039 Spanish adolescents from diverse education centers, Musitu et al. (2007) found that family and scholastic self-esteem showed a protective effect from drug and alcohol consumption, while social and physical self-esteem constituted risk factors.

In the case of alcohol, Luhtanen and Crocker (2005) found that self-esteem did not predict consumption, but narcissism and personal self-valuation based on appearance (extrinsic self esteem) did. Unstable self perceptions that were dependent on external validation were vulnerable to threatened egocentrism or to drops in self esteem in situations where one is judged on the basis of superficial characteristics. Summarizing, the authors concluded that in this sample of study participants, the use of alcohol is motivated by interest in self-esteem or threatened egocentrism, although the important thing is not whether self-esteem is high or low, but rather whether or not it is vulnerable to threat (Luhtanen & Crocker, 2005). In a meta-analysis, Vazire and Funder (2006) examined 23 correlations between narcissism and impulsivity, arriving at a calculated effect size of r = 0.41. In the same way, other studies have demonstrated the association between narcissism and behaviors related with impulsivity such as abusive consumption of alcohol (Luthtanen & Crocker, 2005), sexual promiscuity (Foster et al., 2006), irrational betting (Campbell et al., 2004), compulsive purchasing (Rose, 2007) as well as the association between narcissism personality disorder and consumption of opioids (Calsyn et al., 1996).

Temperament and predisposition

Epidemiological studies show an elevation in co-morbidity between oppositional-defiant disorder, conduct disorder, and attention deficit and hyperactivity disorders in infancy and in adolescence, which all are precursors to abuse and dependence on drugs (Amstrong & Costello, 2002). A very extensive literature exists on the interaction between drug abuse and personality characteristics such as sensation seeking, impulsivity, and antisocial personality (Caspi et al., 1996; Cheong & Nagoshi 1999; Clonninger et al., 1988; Finn et al., 2002; Howard et al., 1977; McGue et al., 2001). The hypotheses posit that all of these patterns present in common an underlying deficit in the capacity to inhibit impulses (Young et al., 2009).

In their attempt to integrate difficulty in inhibiting impulses and development of narcissism, Thomaes et al. (2009) propose that development of narcissism would take place through the interaction of temperament as a predisposing factor activated by maladaptive experiences of socialization. Specifically, the adolescent temperament called “approach temperament” characterized by elevated intensity of pleasure, elevated activity, impulsiveness, lack of shame, ineptness in social relations, extraversion and competitiveness, would translate into an elevated sensitivity to gratifying stimuli, risky behavior, orientation toward obtaining personal goals, such as vulnerability to drug abuse.

In contrast with approach temperament, “avoidance temperament” would be characterized with elevated sensitivity to negative or undesired stimuli, with elevated predisposition to experiencing shame and with that an elevated predisposition to covered narcissism. Joined with these two types of temperament, paternal relationships characterized by overvaluing and excessive indulgence, or excessive frigidity and lack of support would interact to develop and potentiate narcissism. Definitively, this model proposes that the individuals predisposed to depending on gratifying stimuli and exposed in contexts of environmental stress such as, for example, family dysfunction, can develop a dependence on external validation that makes them feel special and develop problems of substance use (Legrand et al., 1999). King and Chassin (2004) in a sample of 454 adolescents belonging to families with alcoholism found that parental alcoholism was associated with lower level of control of adolescent conduct and with that an increment in development of drug consumption disorders. The protective effect of maternal support disappeared when parental control was lowered through use of alcohol. The protective effect of support disappeared at high levels of parental infra-control. Along this line, Wootton et al. (1997) studied a sample of children and encountered that at elevated levels of traits of cruelty and frigidity the protective effects of styles of child rearing were minimal. This circumstance can be expected to generate a subgroup of adolescents with high infra-control, whose risk of drug consumption is so elevated that protective factors have no effect, and whose trajectory in the consumption of drugs differs from those who experience moderate levels of infra-control.

Psychopathy, shame, guilt, empathy and consumption of drugs

Psychopaths present more risk than non-psychopaths of abuse or dependence on drugs, according to findings of both clinical and epidemiological studies (Derefinko & Lynam, 2007; Smith & Newman, 1990; Tourian et al., 1997, Goldstein et al., 2007a, 2007b), without a specific association to a specific drug (Mariani et al., 2008). The association of psychopathy with other personality disorders such as, for example, borderline personality disorder and antisocial personality disorder, may be due to common personality features, such as temerity, perception of invulnerability, impulsivity, absence of empathy, or violent conduct (Chapman & Cellucci 2006; Fritz et al., 2008; Martinotti et al., 2009), all of which are associated with consumption of drugs and behavior that is risky for health (Goldberg et al., 2002; Greene et al., 2000).

The pathways by which authors have suggested a common etiology between psychopathy and drug abuse have been various, citing such factors as tendencies to seek novelty, impulsivity and disinhibition (Krueger et al., 2002; Patrick et al., 2005; Sher & Trull, 1994; Zuckerman, 1979). Nevertheless, recent studies reveal that certain personality features associated with psychopathy also should be taken into account at the point of explaining that association. Two different subtypes of psychopathy described by Gudonis et al. (2009) in terms of their negative emotionality involve predisposition to experiencing states of dysphoria, anxiety, depression, frustration, hostility, alienation and rage. A first type, with low levels of negative emotionality, would qualify primary psychopaths, emotionally stable, with tendency to criminality, higher level of antisociality, ostentatious narcissism and with lower probability of becoming involved in a pattern of alcohol and drug abuse. In contrast, the second type involves high levels of negative emotionality, with a later onset and characteristics of borderline personality, with aspects of covert narcissism and higher probability of receiving a diagnosis of alcohol or drug abuse. This concept brings forward the possibility that two types of psychopathy exist, one with greater reactivity and emotional activation, with elevated features of covert narcissism and less emotional activation, the other with elevated ostentatious narcissism and less emotional activation. Absence of empathy and the absence of guilt would be characteristic features of psychopathy.

In consonance with the study of psychopathy, empathy has also been described as a protective factor from SUDs in adolescents (Nguyen et al., 2011). Similarly, lack of empathy (Martinotti et al., 2009), specifically emotional empathy, has been described as risk factor (Maurage et al., 2011, Amenta et al., 2012, Preller et al., 2014). These studies show that alcoholic patients have difficulties in understanding the emotional state of other people (Pagano et al., 2016) but they maintain the capacity to understand their goals, desires and ideas. Empathy would mediate substance consumption through self-regulation mechanisms.

Narcissism as feature or state: the narcissist state and self-induced narcissism

Recent Studies describe that personality (Ferguson, 2010; Lucas & Donnellan, 2011; Specht et al., 2011) and self-esteem (Orth et al., 2010) change in the course of life, with major changes in the end of adolescence and beginning of adulthood, due to social demands and life experience. Given the instability of personality disorders, Reich (2007) proposes the existence of a Personality State Disorder that would characterize an episodic dysfunction of the personality different from the disorder of personality features.

Healthy narcissism is necessary for the achievement of success, the perception of personal rights, interaction with others, and self-control. We should not forget that although narcissism may be a feature. we also recognize a variety of narcissism that is sensitive to environmental factors, situational and limited (Ronningstam, 2005). The search for a “narcissistic state” that permits personal overvaluing through a sensation of control, success and power can be an alternative to a life with scarce significance or social success and with little habitual self-esteem. Some authors have asserted that alcohol and drug consumption can constitute a defensive action of self-protection as a predominant mode of attempting to compensate for the vulnerability of narcissistic features, concretely, fluctuations in self-esteem, attempting to maintain control and manage impulses and affect (Ronnigstam 2005). According to this author, the most serious forms of narcissism, especially in those whose predominant features include intolerance of affective reactions, instability of self-esteem, or excessive susceptibility to humiliation, make some narcissistic patients more apt to abuse drugs. Thus, the search has been conceived for the effect produced by the use of drugs as a defense mechanism or compensation, but little attention has been given to the investigation of the effect of consumption as an objective in itself in relation to narcissism.

The following segments are excerpts of interviews with persons who were receiving treatment in health centers where addiction is not presumed to be a motive for requesting treatment. The authors chose these narratives because they reflected the relationship between narcissism and drug or alcohol abuse. Nevertheless, these patients fulfill DSM criteria for SUDs.

José is 50 years old. He is retired through an accident, bachelor, does not work or have responsibilities. His principal motivation lies in the seduction and establishment of relations with women younger than he. For him, drunkenness allows a feeling of increased self-esteem, including of triumph and control of the passing of time. The act of recognizing addiction supposed an act of humility.

José.-… “with alcohol I become young again; alcohol has given me moments of many happinesses. I become young again, dominating the situation. My self-esteem is potentiated, and I can be again the one I was with the girls. When you’re in a drunken state you feel triumphant over everything that’s around me, including the alcohol itself…I begin a day with a glass of wine with the meal, and I savor the meal. I’m in control and I think that I dominate the wine. The next day I drink several drinks without passing out, and as I get a little sparky, I also feel like I dominate it more. “

Int. - “How did you decide to stop drinking?”

José.-“The other day I looked at myself in the mirror and I said to myself: ‘I’m an alcoholic’…it was an act of humility for me and it made me able to ask for help”. (José, age 50 years).

Miguel is 32. He works as a custodial worker. In his discourse he illustrates induction of grandiosity with cocaine and alcohol, in contrast with the habitual perception he has of himself and the moments in which he habitually feels inferior without cocaine and alcohol. Finally, he indicates how his habitual management of high quantities of consumption, including injection, among other means, has come to reinforce his concept of invulnerability.

Int. – “Did you take much cocaine, to the point that they had to take you urgently to the hospital…did you get to that point where you even got into physical danger?”

Miguel.- “I believed that I was the King. I’m always afraid, and alone. But that day, I was speaking to people. I was going from one place to another, to a bar and to another…I was the King. I didn’t stop talking, and things occurred to me, and I could talk to any stranger equal to equal…”

Int. – “The king?”

Miguel.- “I felt more of a man, stronger. I always think I’m inferior because I’ve been a junkie and always I go around with my head down. I’m ashamed…but then I feel that I’m another person… that I’m not a junkie.”

Int. - “You drank?”

Miguel.- “Alcohol and methadone and pills…what I stole. With cocaine I like to isolate myself. I do it at home alone and I put myself to watch tv. Normally I don’t put myself as a talker. I get paranoid and think that they are talking about me and because of that I do it in the house because I think they are talking about me. I feel good, pleased. I don’t eat my head (I am not worried). I feel as if I were normal. I find myself looking at television. I laugh at the film. Generally, I’m not a person who laughs and is content … and what’s more, at home I’m not paranoid. I find myself lifted in morale. I don’t feel so afraid nor so idiotic. I don’t feel inferior to anyone. I see myself as more. I see myself as better. With cocaine and with alcohol I feel the same with the two things… I believe that I haven’t quit drugs because I eat my head, and without drugs I feel full of complexes.”

Int. – “You refer to….”

Miguel.- “What I have done with my life…I’ve robbed. I think that I’ve done that to my parents. I’m ashamed of myself, and with alcohol and cocaine I feel equal with others and even better. With cocaine I feel as if I were King. It makes me clean and do things. I feel pleased with myself. I don’t feel inferior…in few words, if I don’t drug myself I think that I’m a shit. Everything has gone away from me when I’m not drugged…when I think more that I’m inferior is when I drug myself.”

Int. – “You put yourself in a situation where they had to take you to the hospital because they found you unconscious in a building site…"

Miguel.- “ I never thought that such a thing would happen to me… an overdose!. I never had thought about death. I never thought that I was in danger. I never have lost the notion of time. I’ve always controlled. I have stuck myself and used to think that, as I had stuck myself and I have done a lot of drugs and never had that happen, nothing, Well I used to control and nothing was going to happen to me. I’ve arrived at being two or three days with cocaine without stopping and nothing happened to me, and I never believed that anything would happen to me. “

Int. - Invulnerable…?

Miguel.- “Yes, I thought that I could never have an overdose. I have taken so much drug that I thought that by now, it couldn’t do anything to me. I thought that drugs could not throw me down. I had never awakened in a place asking myself what I was doing there… One can see that I spent a whole night in a building site”.

Juan is a male 43 years old, misusing alcohol. He also has a residual schizophrenia, and that brings about important difficulties in his life and in his social relations. He tends to be afraid and he has a strong feeling of inferiority in relation to others, although on the other hand, alcohol makes him feel grandiosity and dominion over obstacles, capable of confronting anyone in an argument.

Juan.-“When I put myself [into a drunken state], I am big…I dominate. I speak with anyone and I’m not afraid of anything. I’m in the bar, I drink the first two drinks and I dominate the conversation. I can speak with anyone and argue with them. It’s a stupendous moment. Then what comes, comes.

Juan Antonio is misusing alcohol and cocaine when he has enough money. Divorced from his wife, he maintains a pair relationship with a companion with whom he is not in love. Jealousy and distrust of others is frequent. He especially fears being disrespected for being homosexual.

Juan Antonio.- ”When I get with alcohol, I an pleased, open, with cocaine, a little more charming. I have a sense of inferiority because of my homosexuality…It happens at times…I become distrustful. I erase myself (I get jealous and distrustful). You think that they are commenting on you…and that creates in me as if it were a hatred for others. It appeals to me to tell everyone that they are low-life, as if everyone were doing bad and should accept me as I am. I provoke them, and it’s a manner of challenging and attacking others. When I get blind, without controlling myself, I make commentaries that can disturb people, but I dominate, I become ironic, but I don’t say it directly. It’s challenge… with my irony I can, although the day that I drink, I have no idea what I’m doing” (Juan Antonio 34).

Not surprisingly, domination over others is accomplished, and recognition by strangers is sought in these narratives. On other occasions domination and triumph are accomplished through small openings.

Cosme, 38 years old and a bachelor misuser has had several automobile accidents because of drug consumption. Hyperactive since infancy, he has developed all kinds of risky sports in which he has demonstrated to himself domination over the sea, the air, speed, and risk in general. He is a long-time enrollee in a center for drug treatment, and he has returned to consuming drugs after being at the point of finishing the program. The sensation of triumph is obtained at the same moment as the beginning of consumption after a long process of abstinence where he can waste the effort he made during this time. The triumph let loose the quest for the deserved prize and the same initial consumption the sensation of dominance over cocaine. In this case, the same consumption of cocaine initially fosters the perception of dominance over addiction.

Cosme -“I was for a long time in the residence…and I had arrived at being a monitor…I had overcome a hard stage of my life and I was then in the last phase. I went out to pull out a bill to return to Thailand and decided to celebrate the triumph. I had triumphed over addiction! I had to celebrate that! And I gave myself an homage of cocaine. I think it is domination and triumph. I even put on a cap, began and then saw that I could dominate even the consumption. It was like I was triumphing over cocaine and celebrating with cocaine”

Salvador, 32 years old, is still a student in chemical science. He explains that when he is drunk at a discotheque, same as others, it may be that he is looking ridiculous, but he thinks himself King. He forgets that impossible or unattainable things exist. He also forgets whatever responsibilities he has. The King, among other things, means being attractive, especially to the girls by means of entertaining occurrences and manifested in a state of mental lucidity. Lucidity, the sense of mental rapidity supposes a state of evoking an intelligent self, an important value for a licensed University person.

Salvador -“…An optimism, you feel optimistic, physical pleasure, pleased, the muscles…capable of doing anything. The first time you smoke it makes you feel very well and then under in intensity, but each time less. You feel optimist. You’re with one. You think about your future and you see everything done. You see yourself triumphant. If you’re in a bar you are the charmer of the bar, the object of attention. You feel respected. “

Int. – And at home?

Salvado - “I realized that it was a substance, to say enough when you’re tired. Once I went to my room…a limited idea…fixed on something, always thinking, about something simple.”

Int. – But if you’re alone…

Salvador - To be pleased with yourself, you assimilate, like something positive. You see yourself as capable of facing it all, and you feel physically well…

Int – And amphetamines?

Salvador.- “ That doesn’t have anything to do.. But I could study much…could be pleased to study. But when the examination was over, I could relax. I could read…more centered…and it didn’t give me depression…Another thing is combined with alcohol…you lose the feeling of responsibility… Instead of dedicating myself to studying, I dedicated myself to chatting or things that don’t matter or to go out there…I wouldn’t study…on one side evading responsibilities to do whatever thing that didn’t matter, you clean your room. You become more hedonist…enjoying pleasure of the senses…smoke cannabis. I look for the things that make me feel pleasure. You lose your sense of responsibility…alcohol is an analgesic for my anxiety. I notice that I like to read. I can’t and alcohol makes me forget that I can’t. I do two brandies and I distract the mind and I dare more to say things. It’s not an exaggeration when one is in the cube of the discotheque drunk, the people think he’s being a fool, but he thinks he’s King. It gives you self confidence that makes you believe that you are expressing yourself better. When I talk with someone, I find myself more confident. I have a little push to speak with others and it makes me forget my anxiety. It makes me forget that I can’t do something. When I know people I lose interest. When I write on internet, I’m disinhibited, same as when I speak with someone, you lose the fear. You’re more sociable and amiable…”

Int. – “In relation to another person?”

Salvador - “ I was speaking in general… I used to tell things about myself that I wouldn’t have dared say, intímate sexual things, more lucid…It’s a combination of things. Others interested me more, I saw myself loose, stimulate myself, change the mode of passing the day, changing the way of perceiving everything.

Int. - How do you change the way of perceiving yourself?

Salvador - “I’m more entertaining and happening. It’s more agreeable to be with me and I raise interest, but then they say that it’s not so… “

Alicia is 40 years old. She has been a very attractive woman. She is misusing cocaine and alcohol. For a time she used heroin. At this time she does not use and her security in personal relations with men has changed since then. She has had dinner with a man who was attractive to her, but she could not take the initiative because of insecurity. In addition to triumph in physical seduction, drugs give her creativity, ingeniousness, and amiability, very important complements to physical attraction.

Alicia - “With alcohol, I would have taken off my shoes and I would have touched him with my foot under the table. I would have insinuated much…I would have come on in an exaggerated way, and this time I stayed, not knowing what to do.”

Int. - “And before?”

Alicia - “I created for myself a marvelous world, as if we were different from the rest of the world. You seek someone special. You seek to unite yourself in a way different from the rest of the world, with more security and I used to behave that way. With cocaine, I was the queen. That means that what I say is what is done. I am a god… the one who dances best, seduces more, more charming, more sexy and ingenious, more creative. Heroin gave me peace. I was capable of everything. I wrote incredible poetry. I was creative, different. It was easy for me to awaken these things with drugs. With smoked cocaine, all of these things are integrated.”

Narcissist context also is in the surroundings and the social position of the medium where we are involved.

Victor is 25 years old. During several years he has trafficked in cocaine, in the environment of discotheques and pubs, the atmosphere of enjoyment. He has no studious background or education. He belongs to a middle class family. He seeks a social position in the small city where he lives and he misses the life that not only cocaine but the social scene gave him. The injection of self-esteem was necessary not to feel failed by having left an atmosphere of triumph and social success measured by fame and the number of girls that wanted to be with him.

Int. – “How did you return to using?

Victor - “You revive old patterns. I missed the atmosphere of before. Who I was before, famous, with many girls, very valued, and respected, admired…to go out only with handsome girls, enter free in the discotheques. It gave me class. I had many friends thanks to the traffic. It gave me status. Admired and respected, also I had more girls because of that. During the day, you went all over. Everybody knew you. You felt respected, that you were more than the others. You had status – a position.”

Int. – How did you feel with respect to others when you drank?

Victor.- “When I used to drink I didn’t feel different. I didn’t climb or fall. I felt the same. I was in a gas company. They fired me and I felt failed. I sought to free myself of that…They had joked about us going through Valencia up and down, and they had tricked us. I take some lines and I forget it all. We weren’t going to eat at home. I was irritated with the company. They communicated that they had fired me and I went to use. I felt that I was no good for the company, neither for that nor for any, and when I did the cocaine, I felt the opposite. I am worth much more. It’s like an injection of self-worth. My spirit rose, the idea of myself. I could find better things. I was moved to and could think better things about myself and think that I wasn’t a failure. “

Luisa is a 40-year-old woman, unmarried. During her infancy and adolescence she had felt special, more intelligent and superior to those around her. That perception is very feeble and she becomes resistent when she consumes alcohol.

Luisa - “I’ve always been peevish…and also misunderstood. When I broke up with my partner, the fact of breaking up with a person didn’t affect me. My pride betrayed me. It was the defeat that couldn’t happen to me. I believed myself to be special, and that it couldn’t happen to me. They had told me all my life that I was special. All my life they had told me that I was special. All my life I have thought that I was smart and that life would be easy, life without effort. When he left me I felt very failed and I lost all my self-confidence. I had always been leader of whatever group I was in. There where I had been I had always been leader. It was rare when I didn’t please everybody. To recognize that I am not special would be to lose much. Now my image with my companions is unstable, capricious and not a worker. I get mad a lot when they insinuate that I don’t take my work well or seriously. Having that disaster has been very humiliating, and I’ve become very suspicious. I am very afraid of what people think of me. “

Int. – You comment to me that you have no problems with alcohol and cocaine, but once in a while you have some drinks. You have told me that the other day you had a few drinks when you went to a wedding…

Luisa -“Yes, when I have two drinks, it makes me talk and laugh at everything, when I go to a wedding…”

Int. How do you feel in relation to others?

Luisa - “In relation to others I’m pleased and loose.

Int. - mmm.

Luisa - “Normally I feel insecure, but when I have a few drinks, what people think matters less, and I go with more energy and it gives me security. It’s okay if they look at me, and if I’m not that way I don’t dare because I think that they will be on the watch for the shoes I’m wearing, how I’m combing my hair… “

Int. – and if they think that you are ill-dressed? It seems that that is very important to you…

Luisa - “Well, if I’ve had two drinks I can talk nonsense, then it doesn’t matter, and I respond that they are grotesque if they insinuate something. I feel strong. I start to to play the fool. Then I don’t feel weak to what people say about me. It’s as if I were another. “

Int. – You feel special?

“Yes. More charming, more open, more smiling, more sociable. I dominate the situation.

Daniel is a 60-year-old street cleaner. He offers a clear example of searching for a narcissistic state in vulnerable self-esteem

-Int. – You say that you need to drink two beers when you work. Can you talk to me more about that?

Daniel - “ Yes, well … I work as a sweeper and before people passed by you, you did your streets and that was it. Now with the crisis, they demand more. The Company presses you more and once in a while they tell me that I’m lazy and a dog and I’m worthless for work .

Int-“,mmmm”

Daniel - “I have a lot of self love and a woman comes to the door of her shop and the woman says to me, ‘You have no idea.’ I am a person who takes offense at anything they say to me. I have much self-love. Whatever they say to me lights me up”.

Int.- “ And you drink some beers?

Daniel - “ If I drink I find myself stronger, I’m more of a man, more than anything. If I don’t drink, I feel without strength, like a coward. I drink two beers and I tell myself, ‘This guy doesn’t bother me.’ I have two beers and it passes.”

4.5. The narcissist context and the narcissist epidemic as risk factors in the consumption of drugs – Epidemiological studies on a large scale, such as the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) find that young age involves a significant risk factor for dependence and abuse of drugs, annually, and during the respondents’ lifetimes, confirming that adolescence and youth are particularly vulnerable periods for the abuse of drugs, as first use tends not to happen at later ages (Compton et al., 2007).

The same data also show more elevated rates of drug use disorders among persons between 30 and 40 years old, who grew up and developed in the 1970s. In recent years also there has been an increment in these rates as these generations age (Compton et al., 2007), indicating a potential cohort effect in the younger ages, although the rates of drug abuse have been holding stable. In short, until now the cohorts of persons were replaced in the university by more recent cohorts who were experimenting with drugs before leaving high school. In the 1960s the epidemic began on university campuses and later extended to younger ages, that is, at institutions and basic education. Nevertheless, in the last years, since the 1990s, the graduated cohorts in the middle and late 1990s brought with them the pattern of using hard and illegal drugs that had surged in secondary schools at the beginning of the 1990s. In the 90 s the increments of illegal drugs were substantially greater in the persons with secondary education than in the university population or the young adults. These data lead to predicting that as a generational change will take place, there will appear an increase in illegal drugs in young adults (Johnston et al., 2011a).

The trends of illegal drug consumption in the United States from 1976 to 2010 show that the prevalence of drug use in all age groups from 1976 until the beginning of the 1990s fluctuated in parallel (Johnston et al. 2011a, 2011b). Prevalences of drug use maintained similar figures in all of the age groups, evolving with one pattern, diminishing or increasing equally. At the beginning of 1994-1995, especially in age groups that in that moment were 25 years old, that is, among those born approximately in the beginning of the 1970s, prevalences of consumption of illegal drugs began to differentiate in function of the age cohort. At the beginning of those years, the proportion of persons who consumed illegal drugs among young persons was influenced also by the effect of the same generation of membership, independently of the common factors for all those ages. Johnston et al. (2011a, 2011b) found that prevalence of alcohol use also is influenced by period effects and cohort effects, although it is less evident than in the case of illegal drugs.

Conclusion

Substance Use Disorders (SUDs) are characterized by their multifactorial nature and their dynamism. Their causes and maintaining factors are heterogeneous, varying according to the type of drug, the user and the context of use. The absence of empathy and the perception of invulnerability are important characteristics in a considerable number of cases of SUDs that also form part, among others, of the most important characteristics of narcissism. One of the criteria for SUDs of the DSM-5 specifies the continuous consumption of a drug in spite of damage to health, personal economy, safety or personal relationships. Therefore, this behavior implies not only a lack of empathy toward others’ feelings and needs, but also the perception of invulnerability. These symptoms also characterize the narcissistic personality disorder, and for this reason DSM-5 recommends that they must be differentiated, setting apart narcissistic traits from symptoms that can develop in association with the continuous use of substances. In the current paper we suggest that these traits are not only the result of drug consumption, but also that they can be at first a risk factor for the initiation into drug misuse, secondarily, the goal that people look for, and finally, its maintaining factor.

Without trying to offer an exhaustive explanation of SUDs, narcissism helps us understand the sparse motivation value of empathy or the perception of invulnerability as they occur in people with SUDs. Methodological insufficiencies, and the different conceptual meanings employed until recently explain the scarce utilization of this concept overall in the context of drug consumption.

Nevertheless, during the latest years, the number of peer- reviewed publications on narcissism has increased significantly (Miller et al., 2011, 2014). The introduction of the different dimensions of narcissism has led to the need of researching the way they interact and differ. Certainly, the introduction of the operative criteria of Narcissistic Personality Disorder in the DSM was important, and also the inclusion of descriptive text relevant not only to grandiose narcissism but to vulnerable narcissism in the DSM-IV and DSM-5. All the same, although the Narcissistic Personality Inventory (Raskin & Terry, 1988) has been widely used, it does not assess the pathological dimensions of narcissism. Nevertheless, other questionnaires recently developed assess vulnerable narcissism (Hypersensitive Narcissim Scale; Hendin & Cheek, 1997), pathological narcissism (Pincus & Lukowitsky 2010; Pincus et al., 2009) or both (e.g. Five-Factor Narcissism Inventory; Glover et al., 2012). The use of these questionnaires with good validity and reliability have allowed researchers to go beyond the observations based only on clinical practice and theoretical hypothesis. Narcissism has come to be defined as a dimension that develops from healthy narcissism into psychopathy, being conceived at once as a characteristic in a process of interpersonal relationship to create, maintain, and raise a grandiose self-perception, in search of reinforcing confirmation of self-esteem based on interaction with others. It should be distinguished from self-esteem and it should be understood as an adaptive feature in the context of our society. Narcissistic people are not characterized simply by an elevated sense of self-worth, but rather by an elevated self-esteem, although unstable, and excessively dependent on external reinforcement. Within the narcissistic dimension, healthy narcissism can be distinguished at one extreme, then ostentatious narcissism and covert narcissism, and finally, in the less adaptive extreme, psychopathy that is characterized by impulsivity, a-sociability, lack of empathy, perception of invulnerability, egotism, and an egocentric vision of oneself.

As a predisposing factor it is important to consider that egocentrism and invulnerability are characteristics that define adolescence, a stage when social identity and reputation are established and when drug misuse is highly prevalent. During this period, healthy narcissism is useful for love, creativity, coping with challenges and to achieve success. It is useful to build a sense of control of impulses and the capability of influencing others. It is a normal phase in the process of adolescence that contributes to the development of a sense of independence, autonomy, individualization and stable self-image. It contributes to modeling objectives, the perception of having rights and relating to others. Nevertheless, this phase’s potentiation originates problems related to aggressiveness and antisocial conduct, probably due to its reinforcement of an overvalued concept of oneself. When parents are incapable of correcting them adequately and do not involve themselves in parental responsibilities, the education in self-control will fail, potentiating impulsivity. Besides, if there is no possibility of success or prestige via the routes of the system, unconventional ways will be used to establish a reputation. Antisocial conduct or the consumption of drugs can be one of these ways, especially if the objective is establishing an overvalued vision of oneself or a pattern of domination.

To understand narcissism appropriately as a goal, that is, as an effect sought by the abusive consumption of drugs, it is essential to take into account the different typologies that recent research has identified. The kinds of narcissism enable us to understand it beyond a simple display of arrogance or egocentrism. From the emphasis on ostentation and grandiosity, as it was contemplated in the DSM-IV, the DSM-5 emphasizes emotional and interpersonal regulation. Therefore, narcissistic traits would be the result of a process where the subject aims to be well, regulating his well-being through doses of self-esteem in his relationships with others by obtaining admiration or by his way of responding to humiliation. This concept points to a more dynamic and changing view of personality traits. Beyond a rigid trait, it shows a characteristic, in consonance with some perspectives that conceive some personality disorders not as fixed traits, but states of limited duration (Svrakic et al. 2009). Due to the fact that features of personality are not inalterable during a person’s life, the concept of states of personality has been proposed. The qualitative description of the interviews with participants presented indicates a quest for emotional states beyond relief from disagreeable affective feelings. In cases of lack of social success and high sensitivity to failure or criticism, the search for a “narcissistic state” can give a sense of control, success or power. Consequently, the self induction of that state by substance consumption can be an important, although unstable, resource that can give or enhance a sense of control, power or triumph. Similarly, some individuals who find their identity in audacity and violent behavior need coldness and lack of empathy to succeed, and substance consumption can help to attain this state.

For that reason, substance intoxication can be conceived as a self-induced narcissistic state that is sought by the consumer. As long as narcissism is an interpersonal relational phenomenon, likewise, it can take the form of drug consumption. Our conclusion is that, in the same way we conceive narcissism as a way to regulate self-esteem, we can also consider some patterns of SUDs as mechanisms of self-esteem regulation by means of self-inducing a “narcissistic state”. We propose that it is not only that some people who feel inferior or insecure look for a state of drug intoxication, but it is that some people who want to achieve a feeling of superiority seek a narcissistic state by means of this state of intoxication.

One of the most important motives for the consumption of drugs is the quest for positive emotions. Given that an important source of negative emotions resides in the perception of humiliation or threat to personal dignity, people with narcissistic features are more predisposed to the use of alcohol and drugs. The relation between impulsivity, consumption of drugs, and narcissism is also proven. On the other hand, if in fact the literature is broad in documenting the association of the feature of psychopathy, and especially the narcissistic features of psychopathy with drug use disorders, the concept that persons with drug use disorders present low self-esteem is controversial. Although this hypothesis should not be discarded, a high percentage of people treated in programs of drug abuse treatment present features of narcissism, especially covert narcissism. That is, unstable self-esteem instead of low self-esteem. In these contexts of frequent lack of personal success combined with elevated pride, shame and high sensitivity to humiliation can be confused with low self-esteem. Narcissism can also be a maintaining factor lessening motivation to change. On the one hand, lack of empathy hampers the subject’s ability to consider the harm caused to others, and on the other hand, invulnerability gives an overvalued sense of the ability to control negative consequences for health or interpersonal relationships.

An improvement in understanding change and maintenance processes of SUDs can contribute to developing better ways of personalizing treatments. For example, in the process of a treatment, an accurate assessment of feelings of guilt based on expressions of repentance could help to evaluate the evolution of the process of recovery; the identification of interactions of humiliation that predispose to regulate self-esteem by drug consumption could help to clarify contexts of increased risk of relapse, and on the other hand, empathy training could be an essential intervention for these subjects.

Finally, personality evolves in constant interaction with cultural context, that is, a grouping of ideas, values and roles that an individual should develop in society. One feature of cultural context involves the individualistic/collectivistic contrast. Another feature involves cohort effects in which different generations experience different experiences of inculcation. In the West, some authors have posited a “narcissist epidemic” attributable to over-emphasis on formation of inflated self-worth. These experiences did not occur in earlier cohorts.

These explorations of the relationship between narcissism and substance abuse certainly require additional investigation and refinement, but they suggest new approaches to the condition of drug abuse that have not been part of the treatment repertoire. Where the underlying assumption of treatment is that drug abusers have low self-esteem, the evidence presented here finds drug and alcohol abusers employing intoxication to feed the narcissistic need to feel superior to others. This process demands more attention in efforts to treat drug abuse problems.