Arnold Cooper has explored the intimate interweaving between narcissism and masochism in both normal development and pathological character. He argues for the union of the two categories into a single “narcissistic-masochistic character”. He illustrates the ways in which masochism is used to defend against and repair narcissistic injuries by turning passively experienced frustrations into actively sought-after mastery over pain. This mastery in turn becomes a major source of narcissistic gratification, and therefore narcissistic pleasure is pursued through masochistic defeat and frustration. A self-reinforcing cycle is thus established. Whether the surface clinical presentation appears more overtly narcissistic or more overtly masochistic, a short period in treatment

will reveal that both types share the sense of deadened capacity to feel, muted pleasure, a hypersensitive self-esteem alternating between grandiosity and humiliation, an inability to sustain or derive satisfaction from their relationships or their work, a constant sense of envy, an unshakable conviction of being wronged and deprived by those who are supposed to care for them, and an infinite capacity for provocation.

Cooper also has emphasized the pathological harshness of inner conscience - the superego - in patients with narcissistic personality disorder. The defensive grandiosity that characterizes these patients creates an unending series of discrepancies between their inflated fantasy goals and achievements and the actuality of their accomplishments, even when the latter are at a very high level. In effect, the voice of conscience tells them, “You are a failure. You did not deliver all that you promised. You are not as big and strong as you pretend to be.” The incapacity of narcissistic individuals to defend against these charges is a major source of their inability to sustain interest and pleasure in their activities or in the objects that are close to them. Nothing they do or have measures up to their grandiose fantasies. The inner denigration of their accomplishments often results in guilty depression and is commonly projected as denigration of the therapist, usually after a brief initial idealization. Furthermore, a considerable portion of the provocative, self-defeating behavior of narcissistic patients represents their feeble efforts to defend themselves against their superego. These patterns may be modified with consistent awareness and interpretation of the severity of conscience and of the patient’s inability to defend against inner self-reproaches. The therapist, whether viewed as a selfobject or as an auxiliary ego, helps provide the initial strength needed to cope more successfully with the barrage of inner criticism.

Summary
The diagnosis of narcissistic personality disorder involves the use of several types of data: observable behaviors such as arrogance, entitlement, contempt, shame, or shyness; manifest, covert, or unconscious fantasies and feelings, such as grandiosity, uniqueness, and envy; and a quality of object relations manifesting itself in the transference and in the life history as unempathic, exploitative, devaluing or idealizing and in which the therapist is treated as an extension of the patient.

We again caution against viewing every grandiose fantasy, expression of envy, or devaluation of the therapist as a sign of narcissistic personality disorder. Narcissistic disturbances will be present in all psychopathology, but only in the narcissistic character will a pervasive pattern of these features be found.