Healthy narcissists feel good about themselves without needing constant reassurance about their worth. They may be a bit exhibitionistic, but do not need to play down the accomplishments of others to put themselves in a good light. And although they may like adulation, they do not crave it.
''Normal narcissism is vital for satisfaction and survival; it is the capacity to identify what you need and want,'' said James Masterson, a psychiatrist at Cornell University Medical College. His book, ''The Search for the Real Self,'' published this month by the Free Press, a division of Macmillan & Company, describes the treatment of narcissism. Feelings of Incompleteness
Pathological narcissists, on the other hand, need continual reassurance about their value; without it they feel worthless. Though they have a grandiose sense of themselves, they crave adulation because they are so unsure of themselves that they do not know they have done well or are worthwhile without hearing it from someone else.
''The deeply narcissistic person feels incomplete, and uses other people to feel whole,'' said Dr. Adler. ''Normally, people feel complete on their own.''
With the study of narcissism, the issue of self-esteem has moved to the center of psychoanalytic concern.
''Self-esteem depends on how well-developed your sense of self is,'' said Paul Ornstein, a psychiatrist at the University of Cincinnati, and one of the principal speakers at this weekend's conference. ''We're all exceedingly protective to the extent we feel vulnerable.''
''Narcissistic vulnerabilities,'' as psychoanalysts refer to them, make people particularly sensitive to how other people regard them. ''You see it in marriage, in friendships, at work,'' Dr. Ornstein said. ''If your boss fails to smile when you greet him it may create a withdrawn, anxious feeling. If so, your self-esteem has been hurt. A sturdy self absorbs that; it has a bank account of self-esteem, so it's not unbalanced. But if you're vulnerable, then these seemingly small slights are like a large trauma.''
On the surface, extreme narcissists are often brash and self-assured, surrounded by an aura of success. Indeed, they are often successful in their careers and relationships. But beneath that success, feelings of inadequacy create the constant need to keep inflating their sense of themselves. If they do not get the praise they need, they can lapse into depression and rage. The Workaholic's Reward
Admiration, rather than the pure pleasure of doing things well, is what propels narcissists to their success, psychoanalysts say. Thus many workaholics put in their long hours out of the narcissist's need to to be applauded. And, of course, the same need makes many narcissists gravitate to careers such as acting, modeling or politics, where the applause is explicit.
Many difficulties in intimate relations are due to narcissism, according to David A. Berkowitz, a psychiatrist at Tufts University.
''Narcissism makes someone vulnerable to the least failure to be loved or accepted just as they are by their partner,'' Dr. Berkowitz said. ''Marriage brings to the fore all one's childhood yearnings for unconditional acceptance. A successful marriage includes the freedom to regress, to enjoy a childlike dependency. But in marriage a couple also tend to re-enact early relationships with parents who failed to give them enough love. This is particularly hard on those with the emotional vulnerabilities of the narcissist.''
Narcissists tend to surround themselves with people will will laud them rather than give criticism when it is needed. They are drawn, too, to the trappings of success, such as automobiles or houses that announce their worth to the world. Narcissists find in them support their grandiose sense of themselves.
Narcissists are typically charming and friendly. Their own intense need for adulation makes them sensitive to the same needs in others, and so they are particularly adept at ingratiating themselves. But there is a hidden agenda to their friendliness: they are interested only to the extent that their own self-importance is fed by it.
Those narcissists whose hard work has paid off in making them leaders in business, for instance, tend to try to make their organization recreate the childhood they long for, with themselves at the center of a loving world, said Howard S. Schwartz, a professor of management at the Oakland University School of Business Administration in Rochester, Mich.
Writing in the Journal of Management, Mr. Schwartz proposes that many business organizations tend to reward the narcissistic fantasies of those at the upper echelons, who receive the adulation of those below. When the process becomes pathological, he notes, the organization becomes totalitarian, with those below fearing to do or say anything that does not fit with the idealized view of those at the top. Difficulties During Childhood
At its pathological extreme, the narcissist's intense drive to inflate his sense of grandiosity is seen by psychoanalysts as protecting him from a deep feeling that his life is empty, and that underneath it all he is worthless. The main theories of narcissism have been propounded by the late Heinz Kohut, a Chicago psychoanalyst, and by Otto Kernberg, a psychiatrist at New York Hospital-Cornell Medical Center.
Some psychoanalysts trace the roots of narcissism to difficulties during the period from 18 months old to 3 years, when a child's sense of having a self, independent of others, emerges. When parents need their child to seem perfect, as often happens with narcissistic parents, the child encounters barriers to expressing separateness and establishing an individual identity.
Whenever such children try to express themselves in ways that do not fit with the parental needs, they are attacked, criticized, or ignored. This leaves them feeling inadequate and impaired, and that they can be loved only if they fit the parents' image of their perfection.
The child's resulting fear that no one loves him just as he is leads to a deep belief that there is something repugnant or disgusting about him. It is to protect himself from these feelings that the narcissist builds a facade of grandiosity.
When people disappoint narcissists in their search for adulation, they are prone to turn on them with rage. When life deals a setback, narcissists plunge into depression.
This makes narcissists particularly hard to treat in therapy, for at some point the therapist will have to deflate the narcissist's grandiosity, if only to help him or her find a firmer reality. It is at that point that the therapist risks becoming the target of the narcissist's rage. Role of Fantasy
One of the new treatment approaches to narcissism, developed by Dr. Ornstein and his wife, Anna Ornstein, a child psychiatrist, revolves around what they call the ''curative fantasy,''
''Every patient comes to therapy with certain ideas, both conscious and unconscious, about what will cure them,'' Dr. Ornstein said. ''That fantasy will figure in the cure; if the therapist doesn't respond to it early on, the patient may quit, feeling he'll never get what he wants from this therapist.''
Those fantasies have particular prominence in the mental life of narcissists.
''You see the same sort of fantasy in everyday life,'' Dr. Ornstein said. ''The idea that if I just get this job, or if only my wife would treat me in a certain way, or whatever, then my problems would be solved.''
In Dr. Ornstein's approach to therapy, he views self-defeting habits such as drug-taking and promiscuity as a sign of the patient's curative fantasy.
''These are often failed attempts at self-healing,'' he said. ''If you can acknowledge this, and show him that you, too, are trying to solve his problem, then the patient will feel understood and affirmed. But when the patient feels the therapist doesn't understand, he experiences a lack of attunement. Such periods will come and go during the course of a successful therapy with narcissists. Its part of a reparative process, an emotional equivalent to the early love the patient didn't get. It eventually helps them build a sturdier self.''
One of the more novel approaches to healing the narcissist's wounds is through meditation. Writing in the Journal of Transpersonal Psychology, Mark Epstein, a psychiatrist in New York City, proposes that certain experiences in meditation offer a natural corrective to the narcissist's fragmented sense of himself.
Dr. Epstein proposes, for instance, that the intense experience of delight that sometimes occurs during meditation can reassure the narcissist that he can find a sense of well-being within himself, and so does not need to depend on others for it.
The narcissist's need for the best of all things can, however, be a problem when seeking treatment. Dr. Masterson tells of having been quoted in an article in The New York Times as an expert on the subject. Within days, a dozen people called him who had read the article and thought they needed treatment for the problem. Each came to him for an evaluation, and he recommended they be treated.
But when Dr Masterson said that he was too busy to take them on himself, and suggested that they be treated instead by one of his associates, not one of the 12 returned for treatment.
TOO MUCH OF A GOOD THING Up to a point, narcissism can help a person be more successful and happy, but in more extreme cases it causes serious problems in relationships and careers.
HEALTHY: Appreciates praise, but does not live for it. UNHEALTHY: Has an insatiable craving for adulation; needs praise to feel momentary good about self.
HEALTHY: May be hurt by criticism, but the feeling passes. UNHEALTHY: Is enraged or crushed by criticism, and broods for long period about it.
HEALTHY: Feels unhappy but not worthless after a failure. UNHEALTHY: Failure sets off feelings of shame and worthlessness.
HEALTHY: Feels ''special'' or especially talented to a degree. UNHEALTHY: Feels far superior to everyone else, and demands recognition for that superiority.
HEALTHY: Feels good about himself, even if others criticize. UNHEALTHY: Requires continual bolstering from others to have a sense of well-being.
HEALTHY: Takes life's setbacks in stride, though he may be put off balance for a time. UNHEALTHY: Reacts to the hurts and injuries of life with depression or rage.
HEALTHY: Self-esteem is steady in the face of rejection, disapproval or attacks. UNHEALTHY: Reacts to rejection, disapproval or attacks with sharp rage or deep depression.
HEALTHY: Does not feel hurt if no special treatment is given. UNHEALTHY: Feels entitled to special treatment, that ordinary rules do not apply.
HEALTHY: Is sensitive to the feelings of others. UNHEALTHY: Is exploitative and insensitive to what others need or feel.