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うつ病の症状改善プロセス

強迫スペクトラム障害(OCSD)

ナルシス・ナル君

まず芸能関係から引用
*****
矢田亜希子が赤ちゃんを産んだっていうニュースが報じられたけど、そのほとんどが、ダンナの押尾学が、自分たちのことを「美男美女の夫婦」って言ってのけたって部分をピックアップして伝えてた。たとえば、「日刊スポーツ」には、こんなふうに書いてあった。

（前略）押尾は「男でも女でもどっちでもいい。健康であればね。でもさ、美男美女の夫婦の子供で、かわいい子が生まれたの見たことがない」と、語っていた。（後略）

それで、スポーツ紙の記事を見ながら放送してたワイドショーでも、この部分を取り上げて、「自分で自分たちのことを美男美女だなんて、押尾さんらしいですね」ってコメントして、笑いのネタにしてた。だから、きっと、スポーツ紙を読んだ人たちも、ワイドショーを見た人たちも、みんな、おんなじように思っただろう。なんせ、押尾学は、「押尾語録」ってのが作られてるほど、自画自賛の嵐の天然男だから、こうした記事を読めば、誰もが「いかにも押尾学が言いそうなセリフだ」って思うからだ。

この流れを知れば、押尾学がお得意の自画自賛を炸裂させたんじゃなくて、何でもない普通のやり取りだったってことが分かったと思う。そして、このセリフは、「またまた押尾学が自画自賛のアホ発言をした」って思わせるために、悪意を持って編集されたものだってことも分かったと思う。

押尾学は、「赤ちゃんが男の子だった」ってことに対して、「男でも女でもどっちでもいい。健康であればね」って答えたワケで、そのあとの「美男美女のカップルですから、きっとかわいいお子さんなんでしょうね？」って質問に対して、「でもさ、美男美女の夫婦の子供で、かわいい子が生まれたの見たことがない」って答えたワケだ。だから、このやり取りには、どこにも、押尾チックな部分、テングになってる部分はない。それなのに、この２つのセリフを１つのカギカッコでくくって、いかにも続けてしゃべったように編集されたことによって、ミゴトなまでの押尾ワールドが全開になったってワケだ。

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というわけで、押尾学という人は、銀色夏生だと「ナルシス・ナル君」で、ある先生の好きな言い方だと「ナルちゃん」で、正式の言い方では、ナルシスティック・パーソナリティである、ということらしい。
これが病気にまで高まると、Narcissistic Personality Disorder　と呼ばれ、発音はナルシシスティックであるが、省略して、ナルシスティックでもよいと、小此木先生がおっしゃった。日本語で、自己愛性人格障害である。ナーシスティック。
上記の中に、自画自賛とかテングとかの言葉が見えている。

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「あらゆる星が北極星を中心として動いているように、世界は私を中心として動いている。私は秩序そのものであり、法律そのものである」
シェークスピア「ジュリアス・シーザー」

シーザーだから、これでいい。ただの人がこんな風に思っているとして、ひそかに思って、日記に綴っているだけなら、害はない。他人の前で露出してしまうから、問題で、嫌われる。しかし、きらいな人は離れてゆくだけで、おおむねは問題ないのだが、上司と部下だったり、会社の同僚だったりすると、苦手な人だから離れているというわけにもいかない。上司がシーザーだったら、どうします？
ひょっとして、「そんな人こそ私にふさわしい、喜んでついていく」という人もいるだろうが、あなたもちょっとナルちゃんだ。

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「こんなあさましい身と成り果てた今でも、己は、己の詩集が長安風流人士の机の上に置かれている様を、夢に見ることがあるのだ。岩窟の中に横たわって見る夢にだよ。嗤ってくれ。詩人になりそこなって虎になった哀れな男を」　　――　中島敦　「山月記」より

これもまあ、妻子には迷惑をかけたが、こんな人もいなければ、世の中は進歩しないので、これでいい。わたしはこの人をナルシスティックとはあまり思わないけれど。

自己愛性人格障害は、もっと平凡な人生を歩いていて、平凡な人間なのに、なぜか自分だけ特別だと思っているのである。理由がないのに。
自己愛性人格障害（Narcissistic Personality Disorder）とは、ありのままの自分を愛せず、自分は優越的で素晴らしく特別で偉大な存在でなければならないと思い込む人格障害である。

押尾学と矢田亜希子ならば、かなり特別なのであって、ナルちゃんとは私は思わない。

問題なのは、たとえば、こんな人たち。

御都合主義的な白昼夢に耽る。
自分のことにしか関心がない。
高慢で横柄な態度。
特別な人間であると思っている。
自分は特別な人間にしか理解されないと思っている。
冷淡で、他人を利用しようとする。
批判に対して過剰に反応する。
虚栄心から、嘘をつきやすい。
有名人の追っかけ。
宗教の熱烈な信者。

こんな感じのことを文章で描写すると、次のようになる。

なんでも自分の思い通りになるという空想に耽る。万能感の空想。すべて自分にとって都合のいいように事が運んで、最後には自分が絶大な称賛を浴びるという空想。自分だけが特別に評価されて大抜擢され、とんとん拍子に出世するという空想。
聞かれもしないのに、やたらと自分のことをしゃべりたがる人。話が他へ移ろうとすると、強引に自分の話に戻そうとする。話の内容は自慢話ばかりで、聞いている方はうんざりする。他人にはあまり関心がないので、相手がうんざりしていようとお構いなし。
自分は特別な人間だと確信している。小市民的な生き方を軽蔑し、そういう人達と一緒にされることを嫌う。裏付けとなるものがなにもないのに、一目置かれる存在であることに非常にこだわる。
あるいは、自分という人間は特別な人しか理解することができないのだと思ったりする。たとえば、以前マスターソンがラジオで自己愛人格障害の話をしたところ、自分は自己愛人格障害なのでぜひ治療してもらいたいという人が何人も電話してきた。そこでそのうちの十人を治療することになったが、実際に治療するのは高名なマスターソン本人ではないと知ったとき、十人が十人とも治療を断った。無名の医師ではダメ。
他人に対する共感に乏しく、他人を自分のために利用する。他人の業績を横取りして自分のものにする。優越感に浸るために他人を利用する。
もともと、裏付けのない優越感だから、話のつじつまを合わせるために嘘をつくこともある。本人には嘘をついているという意識はあまりない。ときにはホラ話のように、話がどんどん大きくなっていって、どこまで本当なのか分からなくなる。
有名人に近付くことで自分を特別な存在だと思い込んだりする。政治的な大物に近付いて自分の誇大感を膨らませることもある。自分も同じ世界の人間になったように錯覚して、裏付けのない空想的な野心にのめり込んだりすることもある。

誇大感を持つ人には二つのタイプがある。自分は素晴らしいと言うタイプと、あなたは素晴らしいというタイプである。あなたは素晴らしいというタイプの人は、その素晴らしい人に奉仕している私も素晴らしい特別な存在だと信じる。偉大な独裁者を崇拝する献身的な国民、偉大な神に身を捧げる熱狂的な信者、ワンマン経営者に心酔して滅私奉公する素晴らしい幹部社員、有名な歌手の応援をする熱狂的なファンなど。

すべてに言えることは、ありのままの自分が愛せないこと。自分は優越的な存在でなければならない。素晴らしい特別な存在であり、偉大な輝きに満ちた存在でなければならない。愛すべき自分は、とにかく輝いていなければならない。
しかし、これはありのままの自分ではないので、現実的な裏付けを欠くことになる。無理を通すので、時々は、現実にそぐわないことになる。

しかし、本人にしてみれば、高慢だと言われてもぴんと来ない。それよりは、その人に対して、「あなたは、他人や周囲の出来事を過小評価している」と言った方が理解されやすいかもしれない。自分より優れたものを認めたがらず馬鹿にしているので、他人の能力や才能が見えず、他人の優秀さを無視する。そして、他人を見下したり軽蔑したりすることに快感を覚える。

こんなタイプが上司だったら、どうします？

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ナルシシズムに特徴的な信念体系と性格行動パターンを抽出してみる。通していえることは、「自分は特別だ｣という信念を抱き続けるために、無理をする、現実を無視するということだ。

1.私は、普通の大衆とは異なる特別に非凡で優れた人間である。……おおむね、一般大衆が気に入らない。自分は特別なのだから、一般大衆は、愚かでなければならない。
2.私は、目立ちたがり屋でいつも皆に注目されていたい。……自分より目立つ人がいてはならない。
3.私は、自分の容姿や知性、能力、所作、実績に自信を持っている。……自分は特別なのだから自信を持たなければならない。
4.私は、他人の意見に押し流されないだけの強い自分の意見を持ち、それを理路整然と主張することができる。……自分は特別なのだから、意見も主張も、特別な価値がなければならない。
5.私は、今以上の尊敬や賞賛、崇拝を受けて当然の存在である。……自分は特別なのだから、現在は不遇でも、将来、賞賛を集めなければならない。
6.私は、同一人物に対する評価が極端に変化して気分の波が激しい。（自分を低く評価したり、自分の意見に反対する相手を、公正に評価することはできないし許すことができない）……自分は特別なのだから、そのことを認めない他人に対しては、攻撃しなければならない。逆に、自分を賞讃するなら、その人も特別な人間に属する。
7.私は、鏡に向かって自分の姿を眺めるのが好きで落ち着く。……自分は特別なのだから、まず自分が、自分のすばらしさを確認しなければならない。
8.私の周りには、私を慕って尊敬する多くの人間（取り巻き）がいるべきだと思う。……自分は特別なのだから、周囲の人間は自分を尊敬しなければならない。

以上のように、おおむね、「自分は特別である」という信念を保持し強化するための行動であると解釈できる。

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いつも出てくる、DSM-IVをみてみると、こんな風。
自己愛性人格障害

誇大性（空想または行動における）、賞賛されたいという欲求、共感の欠如の広範な様式で、成人期早期に始まり、種々の状況で明らかになる。
以下のうち５つ（またはそれ以上）で示される。

自己の重要性に関する誇大な感覚（例：業績や才能を誇張する、十分な業績がないにもかかわらず優れていると認められることを期待する）。

限りない成功、権力、才気、美しき、あるいは理想的な愛の空想にとらわれている。

自分が特別であり、独特であり、他の特別なまたは地位の高い人達に（または施設で）しか理解されない、または関係があるべきだ、と信じている。

過剰な賞賛を求める。

特権意識つまり、特別有利な取り計らい、または自分の期待に自動的に従うことを理由なく期待する。

対人関係で相手を不当に利用する、つまり、自分自身の目的を達成するために他人を利用する。

共感の欠如：他人の気持ちおよび欲求を認識しようとしない、またはそれに気づこうとしない。

しばしば他人に嫉妬する、または他人が自分に嫉妬していると思い込む。

尊大で傲慢な行動　または態度。

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つねにこんな感じという人も多くはないけれど、一時的に、こんな感じが強くなるといった程度の人なら、少なくない。

程度の問題だし、場面の問題でもある。ナル君になっていい場面でも、あくまでも謙虚と言うのも、困りものだ。時と場合に応じて、適応的な行動が取れるのが大人である。たとえば、恋愛の一場面では、ナル君になってくれないと、話が続かない。

「自分は特別である」という確信は、残念ながら、現実に反する確信なので、(つまり、妄想的なので)、現実と矛盾し、折り合いがつかず、他人を困惑させ、不愉快にさせてしまう場面も出てくる。
普通は、そのような場面での気まずさから、これではいけないと気付き、現実的な路線をとるものだ。
しかしナルシス・ナル君たちは、あくまで、「自分は特別だ」と信じ続けたいのだ。そのことが現実的な利益をもたらすわけではないし、友人もいなくなり、自分は抑うつ的になり、いいことばかりではないのだが、それでも、「自分は特別だ」と信じたいのだ。

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自己愛性人格障害（ナルシスト）とは、「自分自身を愛する」という行為が病的なほど大きくなり、「自分は重要な人間だ」「周りには自分を理解できない」といった誇大感を持つようになり、ありのままの自分を愛することができず、空想的誇大的自己を保持するために不自然な事態となっている人である。

自分を愛するという行為は、健全な心の発達のためには必要なものであるが、程度がすぎると問題である。
ありのままの自分を愛することができるなら、健全な人である。
しかし、ありのままの自分に満足できないというのも、向上心と考えれば、一面では、悪くない面がある。一時的で限定的なら、いいことなのである。

惨めな現実を受け入れられず、空想的な誇大的な自己を作り出している。これも、自分を守るための、一時的なことならば、いいことでもある。

惨めな自分をすっきりと受け入れて、気持ちも惨めにならないということは難しい。適当なところで、多少の脚色をしながら、自分を慰めながら、だんだんと現実の惨めさを受け入れてゆくものだ。ナル君たちは、その、脚色から、いつまでたっても、抜けられない人と言ってもいいだろう。

でも、そういう人たちには、一種特別なエネルギーがあることがある。「自分は特別」なのだから、人一倍努力する部分があったり、リスクを恐れずゲームに参加したり、そんな面もある。そして、成功してしまえば、その人は一気に、現実に、賞賛にふさわしい人になる。だから、若いうちの自己愛性傾向は、悪いことでもない。いつまでもそのままというのは人生を難しくしてしまうけれど。

「俺は特別だ、甲子園に行くぞ。親父はそのために金を稼いでくれ。お袋は栄養管理をしてくれ。」というくらいでないと、なかなか甲子園にはいけない。「わたしは特別だ、もっときれいになって、せりふも覚えて、デビューするぞ」というくらいでないと、芸能界デビューも難しい。

自分の息子をプロ野球選手にしようとして特別に育てたという人の一部には、ナル君が混じっているのかもしれない。誰でも、自分の子供の将来については、過大な期待を抱き、夢を見る。それは社会的に容認された、ひそかなナルシスティック傾向なのかもしれない。

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誇大感に満ちた空想は現実感を奪う。たとえば、本当は自分が他人に嫉妬しているのに、他人が自分に嫉妬していると思ったりする。他人から批判されると、あれは私に嫉妬しているからだと解釈する。こういう防衛機制によって現実を再解釈して、納得しようとする。

ナルシス・ナル君はなにがなんでも自分が優位に立つ必要がある。どんな卑怯な手段を使ってでも、どんなにつじつまの合わない妄想であろうと、自分を守るためにしがみつかざるを得ない。嘘をついたり、他人を利用したりすることも、「自分は特別だ」という信念を補強するためと考えれば、合目的的なのである。

他人から侮辱されたと思い込んだりした場合、自分を守るために、非常に激しく怒ったりする。あまりにも自己中心的な怒り方であり、周囲の反感を買うが、本人は必死である。自己愛的憤怒と呼んでいる。

妄想の種になるようなものがないときは、他人の欠点を捜し出して見下したりする。ありとあらゆる理由をつけて他人を見下す。貧乏人の癖に、不細工な顔をしているくせに、頭が悪いくせに。実際にどうであるかということよりも、とにかく見下すことができればそれでいい。それは、ただ、「自分は特別だ｣という信念を補強したいからだ。

他人を見下すということは、ときには他人からの報復攻撃として、自分が陥れられるかもしれないという疑いを生み、非常に疑い深くなったりする。他人に心を開くことなく、自分の妄想の殻の中に閉じこもる。これは二次的な必然である。大抵は、こんなことになったらつらいので、「自分は特別だ」信念を捨てるのだが、この人たちは、捨てない。

こういったことは様々な不都合を生む。しかし自我の崩壊を防ぐことができる。もし、妄想が崩れたら一気にうつ状態になったり、あるいはパニックになったりする。少なくとも妄想にしがみついていられる間はこのような悲惨な状態にはならない。

WHOのICD-10では正式な精神障害としては採用されていない。

境界性人格障害でも原因として日本では過保護、アメリカでは虐待が多いという指摘があるが、自己愛性人格障害に関しても似たような言説がある。私としては、そのまま信じることはできない。

まずフロイト、マスターソン、コフートを勉強する。日本語なら、小此木またはその一派の文献が基本。

自己愛(narcissism, self-love)ヘイベロック・エリス(Havelock Ellis)
フロイト(S.Freud, 1856-1939)性的精神発達理論（リビドー発達論）『乳幼児期の正常な自己愛』と『思春期以降の異常な自己愛』

S.フロイトの一次性ナルシシズムと二次性ナルシシズム
一次性ナルシシズムは、『母子分離不安』を弱めようとする防衛機制
マーガレット・S・マーラー(1897-1985)『分離・個体化期(separation-individuation)』

S.フロイトは、正常なリビドー（性的欲動）の充足対象の変遷として『自体愛→自己愛→対象愛の発達ライン』を考えていたので、異性に性的な関心が芽生えてくる思春期以降の二次性ナルシシズムは『病的な性倒錯』であると主張した。思春期や成人期にある男女が、自分の持つ魅力（属性）に自己愛的に陶酔したり、自己の性的身体を自体愛的に欲望するのは、リビドー発達が障害された結果としての性倒錯であり、成人の持つべき生殖能力を失わせる『幼児的な部分性欲への退行』であると言う。

フロイト『自己愛から対象愛への移行』『本能変遷』

二次性ナルシシズム……退行(regression)と固着(fixation)

コフートの自己心理学と自己愛理論。
フロイトは、自己愛（ナルシシズム）を病理的な性倒錯の一種であると考えた。
しかし、自己心理学のハインツ・コフート(Heinz Kohut, 1913)は、自己肯定的な自尊心と活動性の原動力となる『自己愛の発達』を正常な精神発達ラインの一つとした。
『健全な自己愛(self-love)』の成長を促進することで、他者を共感的に思いやる対象愛(object love)も発達し、社会活動に積極的に参加しようとする適応性も高まる。

コフートの自己愛とは、『自己存在の積極的な肯定』であり『理想化と関係する自尊心（自信）の基盤』である。
コフートの自己心理学には『自己愛と対象愛は表裏一体である（自己愛がなければ他者を愛せない）』という信念がある。フロイトにとって、自己愛は『自己愛から対象愛への正常な移行（本能変遷）』を成し遂げられなかった病理的状態であるが、コフートにとっての自己愛は『誰もが持つべき自己肯定感（自尊心）の基盤』であり、苛酷な人生を乗り切る為に必要な“生のエネルギー”の源泉である。

コフートは自己愛の定義として、『自分自身を愛する自己愛』と『自己対象を愛する自己愛』を挙げている。つまり、コフートの言う自己愛とは、自分にとって大切な他者である“自己対象(self-object)”を含むものであり、単純に、内向的かつ排他的な自己愛ではない。(自己心理学では、対象　object という言葉は独自の意味を持っている。)

意欲的な創造性や適度な自尊心を生み出す『健全な自己愛』に対して、自己愛性人格障害の原因となる『病的な自己愛』というのは、自分自身の権力や幸福、名声、成功のみに固執し、自己顕示欲求と誇大妄想的な自己陶酔を満たす為に、他人を不当に攻撃したり身勝手に利用したりする“過剰な自己愛”である。過剰な自己愛は、『尊大さ・傲慢さ・横柄さ』といった言葉で表現される、他者を侮蔑して否定する行動（発言・態度）となって現れる。

実際の自分以上に自分に価値があると妄想的に思い込み、『自分は凡人とは違う特別な人間だから、もっと丁重に敬意を持って扱われるべきだ』といった要求を明示的・暗示的に主張し、『私の実力や魅力、価値を評価できない人間は、物事の価値が分からない無能な人間であり付き合う価値がない（私の実力を高く評価できる人間は、私には及ばないもののなかなか優秀な人間である）』といった排他的かつ独善的な態度を示すこともある。他者に自分への賞賛と従属、関心を強制して、自分の力を認めない人や自分に従わない人たちを遠ざけることで（お世辞やご追従を言うご機嫌取りを周囲に集めることで）、外部の現実原則から自分を守ろうとする。

こんな人がいてもかまわないけれど、そして、その人がそれで得をするもと思わないけれど、そんな人と否応なく付き合わなければならない人は大変だ。やっと異動になって自分は逃れられたと思ったら、友人が今度はその人の部下になってしまい、慰め役になってあげたり。

自己愛が過剰に強くなることで、自己愛性人格障害や演技性人格障害といった病理的な人格構造が形成されてくると、現実的な自己評価を逸脱する誇大自己の拡大が起こり、その結果として特異的な行動パターンを示す。即ち、尊大（横柄）な態度や傲慢な発言が多くなり、自己顕示欲（エゴイズム）を満たす為に他人を利用しようとする。本人は『自分には他人を利用して満足を得る当然の権利と能力がある』と思い込んでいるので反省しない。自分を批判する者や自分の価値を引き下げる対応をする者は許すことが出来ないので、衝動的に激しく攻撃したり(自己愛性憤怒)、防衛的に無視して距離を取ろうとする。病的な自己愛の持ち主と一緒に居る相手は、独特な不快感や違和感を味わわされることになり、自己愛性人格障害の人は、一般的にわがままで自己顕示欲が強い人、傲慢不遜で非常識な性格の持ち主といった形で認知される。

『病的な自己愛＝自己愛性人格障害の原因となる自己愛』もあるものの、自己心理学の自己愛理論では、適切に自己愛の強度と内容を調整できるのであれば、自己愛性人格障害のような人格構造の歪曲の問題は起きないと考える。
『良い自己評価を伴う正常な心理構造』の一部である自己愛や承認欲求（社会的欲求）は誰もが持っているものであり、自己愛そのものが病理的な悪影響をもたらすのではなく、自己愛のバランスの崩れや調節障害が自己愛性人格障害の苦悩や被害を生み出す。このあたりの論述がフロイトとの相違点である。

コフートは、人間は誰もが発達早期に受けた心理的な傷つき（欲求充足の欠如）を抱えているという『欠損モデル』を前提にしている。
生まれて間もない自他未分離の状態にある乳幼児は、母親・父親からの保護と世話を必要としており、その生存を全面的に養育者に依拠している。発達早期（0～2歳くらい）の乳幼児と母親は、二人の間にある境界線を意識しておらず、『幻想的な母子一体感』に浸った状態にある。

マーラー、ウィニコット、ボールビーなど。母子関係を扱ったりしているものは、なかなか難解。

しかし、実際には母親も不完全な人間で、子どもにミルクを与える時間が遅れたり、離れた場所にいて子どもの泣き声が聴こえなかったり、子どもが我がままを言って母親が怒ったりすることがある。そういった瞬間に幻想的な母子一体感が破られて、乳児は『幼児的な全能感』が通用しない欲求不満を感じ、『欠損モデル(defect model)』でいう心（自己愛）の傷つきや欠損を体験する。こういった欠損の存在は全ての人間にあるものであり、発達早期に欠損を感じた経験が自己の不完全さや欲求不満につながり、理想化や誇大性を求める『自己愛の起源』になる。

H.コフートは、自己愛の発達を対象愛の発達と同様に『正常な精神発達過程の一つ』と考えた。
中核自己(nuclear self, 私が私であるという自意識)の自己愛の発達過程には、『誇大自己(grandiose self)』と『理想化された親イマーゴ(idealized parent imago)』という二つのラインがある。欠損モデルに基づく中核自己（自我意識）は、向上心と理想という二つの極（方向性）を持つので双極自己(bipolar self)とも呼ばれる。
誇大自己(grandiose self)は「向上心」の極で発達していき、理想化された親イマーゴ(idealized parent imago)は「理想」の極で発達していく。

共感的な親（反応性の良い温かい母親）の元で、「誇大自己(grandiose self)」の自己愛の発達に成功すると、現実原則に適応できる成熟した誇大自己（自尊心や向上心の基盤）が成長し、非共感的な親（反応性の乏しい冷たい母親）の元で誇大自己ラインの自己愛の発達に失敗すると、幼稚な快楽原則に支配された未成熟な誇大自己（自己顕示欲の強い傲慢さや横柄さ）が強くなる。発達早期の母子関係を重視したコフートは、非共感的な親が乳児の心的構造の欠損（心的な外傷）を大きくして、乳児の精神内界に自己表象の「断片化(fragmentation)」を引き起こし、自己愛の病理の発症リスクを高めると考えた。

自己表象の「断片化(fragmentation)」なんていうことが乳児の精神内界で起こるのかな。でもまあ、このあたり、コーハット的。kohutをコフートとは発音しないだろうな。

「理想化された親イマーゴ(idealized parent imago)」では、親という表象（イマーゴ）や自己対象を理想化して同一化しようとする。その為、発達早期の親が非共感的な反応を示して乳児を無視したり拒絶したりすると、乳児は「最適な欲求不満(optimal frustration)」を経験することが出来なくなり、自己対象である親を理想化する契機（チャンス）を失う。「理想化された親イマーゴ」の形成に失敗するということは、心理内面に安定的に存在して自己愛の支えとなる「対象恒常性」の確立に失敗するということと同義であり、外界に対応する為の心理構造が非常に不安定になる。

共感的な親の元で、「理想化された親イマーゴ」の自己愛の発達に成功すると、自己愛性人格障害の原因となる『不適応な誇大自己』の発達を抑制することが出来るが、それは、精神内界に安定した「自己対象の恒常性」が確立することで「過剰防衛を行う誇大な自己」を強調する必要性がなくなるからである。子どもは自分に価値があるという実感や自分が評価されているという満足の原初的体験を親子関係の中でしていくが、そういった共感的な被承認体験が出来ないと、自己愛的な賞賛と評価を必死に求める誇大自己の拡大が見られるようになる。子どもに対して完全に無関心だったり拒絶的だったりする“冷たい母親”の元では、「理想化された親イマーゴ」の形成に必然的に失敗するので、理想化の自己対象を見失って衝動的な行動や抑うつ的な反応が目立ってくることになる。親の子どもに対する徹底的な無視や冷たい対応というのは、精神分析的な心因論では、うつ病や統合失調症、ボーダーライン（境界例）、境界性人格障害、自己愛性人格障害、反社会性人格障害などの原因になると考えられている。実証的な統計学的研究（疫学的研究）のエビデンスが十分に積み重ねられていないので、「愛情不足の親子関係」だけがそれらの精神疾患（人格障害）の危険因子になるわけではない。

少し前までは、発達早期の心的外傷のようなことがよく言われたが、最近は、やや下火であるように思う。

向上心を伴う『誇大自己(grandiose self)』と理想を構築する『理想化された親イマーゴ(idealized parent imago)』が相互作用することで進む心的構造の形成過程を『変容性内在化(transmuting internalization)』という。コフートの自己心理学に基づくと、自己愛性人格障害の人格形成過程とは、変容性内在化(transmuting internalization)の不適切な進行であり、もっと正確に言うならば、自己成熟へと向かう『誇大自己』と『理想化された親イマーゴ』のバランスの取れた統合的発展の失敗であると言うことが出来る。

誇大自己は、自分自身の鏡像を自己対象とする『鏡面化』の発達過程をたどる最も純粋な自己愛のルーツ（起源）であるが、乳幼児は鏡に写った自分の鏡像を見てナルシシスティックに自己の強力な力や有能性を確信する。露出的で誇大妄想的な誇大自己が強くなりすぎると、自己顕示や支配的野心の抑制を欠いて自己愛性人格障害の原因となる。理想化された親イマーゴは、自分の両親（養育者）を自己対象とする『理想化』の発達過程を形成し、発達早期の母子関係に問題があると、「過剰な誇大自己の発達水準」に固着が起こる。「過剰な誇大自己の発達水準」へと防衛的に退行することで、誇大な自己顕示性と利己主義を特徴とする自己愛性人格障害の行動パターンが生まれる。

「鏡」の比喩はいろいろと活躍する。私も大好きな比喩だ。鏡の不思議さと、自己が自己を認知する不思議さは、やはり、重なり合うはずだと思う。

自己愛性人格障害に見られる傲慢不遜な態度や過度の自己顕示欲を精神分析的に分析すると、『正常な自己イメージと対象恒常性』の形成に失敗した子どもが、不適応な誇大自己の発達地点で発達停止を起こしている状態と言える。つまり、傲慢な態度や自信過剰な発言は『危険な世界』や『信頼できない他者』に対する防衛機制（過剰防衛）の現れであり、幼児的な全能感を抑制して現実的な野心（理想）を持たせるためには、統合された自己イメージと安定した心理構造の再構築を行う必要がある。自己愛性人格障害を予防する『自己の健全な発達』を実現する為には、『誇大自己の鏡面的自己対象』のプロセスと『理想化された親イマーゴの自己対象の理想化』のプロセスが、共感的に相互作用して、『誇大自己の向上心（野心的願望・自尊心）』を現実的なレベルに調整しなければならない。

一応こんな風になるけれど、だからといって、こんな話を信じるわけでもない。空論だとまではいわない。確かに説得力はあるし、背景には、必然性もある。乳幼児の実際の観察を基盤にしつつもある。精神分析が一般に、その説明の背景として、生物学的な理論と結合しつつあるのはとても意味のあることで、それはまさに、初期フロイト的な方向だと思うし、私はその方向が好きだ。

理解不足を棚に上げて、空理空論と言うつもりもない。こんなことを考える人はいるだろう。しかし、それを支持しそれに賛同する人がこんなに多くなっていることに驚く。

ナルシスティック・パーソナリティは大きな問題だ。そしてもうひとつ、ナルシスティック・パーソナリティをこのような仕方で議論して理論化している人たちがこんなにも多いのだという現状を不思議な思いで眺めている。

同じことはフロイトの前期と後期についてもいえることで、私にとってフロイト前期は実に理由があって、天才的だと思う。ニュートンとライプニッツの登場のように、必然的だったと思う。後期は、あまり感心しない。多分、よく理解していないからだろう。