Planetary Health: We Need to Talk about Narcissism

: Concepts of planetary health attempt to collectively address the biological, psychological, social, and cultural factors contributing to “Anthropocene Syndrome”, which encompasses the many wicked interrelated challenges of our time. It is increasingly evident that the wide array of causative factors is underpinned by attitudes, values, and worldviews. Emerging research suggests that certain dispositions or ‘traits’—observable along the continuum from individuals to large groups—may be central to the promotion of health of all systems, at all scales. Here in this viewpoint, we focus on the personality trait of narcissism in the collective context of planetary health. First described in 1852 by pioneering psychiatrist Joseph Guislain, the Mania of Narcissus refers to ‘the patient infatuated with his beauty, his charms, his wit, dress, talents, and birth’. We argue that Guislain’s observations are not restricted to the clinical setting, and that a larger-scale narcissism can interfere with the principles of planetary health. We propose that increasing narcissism, at scales ranging from the individual to the collective, is an important consideration in attitudes and behaviors that undermine health along the continuum of person, place, and planet. Despite a growing body of research directed at collective narcissism, and the role that empathy plays in healthy relationships between humans and nature, it is our contention that the role of narcissism and empathy are important but neglected aspects of the planetary health agenda.


Introduction
Over centuries, the legend of Narcissus has been one of the most popular of the Greek myths. Although there are many variants of the tale, the core narrative presents a handsome and happy youth who is universally admired by those around him. All is well until one day, stopping by a beautiful, deep, and clear forest pool for a drink, Narcissus sees his own reflection in the water (Figure 1). Without awareness that it is merely a reflection, Narcissus returned often to the pool to see his own image, eventually he remained at the waterside full time, neglecting all those around him. Some versions have him abandoning his once-beloved dog [1]. Without self-care in the form of food, drink, sleep, and social companionship, Narcissus eventually died, later to be found in the form of a waterside flower with a drooping head-the flower known today as Narcissus (Daffodil, in the Amaryllidaceae family). Personality traits are often excluded from discussions of larger scale aspects of health and public policy because they are assumed to be mostly fixed over time and are frequently presented as descriptive summaries of behavior relevant to clinical settings [4]. Research, however, shows that personality traits are influenced by environmental factors and have dynamic aspects [5]; features of narcissism are not exempt from malleability [6,7].
Based on available evidence, it is our contention that narcissism, at scales ranging from the individual to the collective, is an oft-overlooked consideration in discussions of health along the continuum of person, place, and planet. Our discussion below is centered around the concept of planetary health which underscores that the health of human civilization cannot be uncoupled from the natural systems within the Earth's biosphere [8]; it has been defined as the interdependent vitality of all natural and anthropogenic ecosystems (social, political, and otherwise) and seeks to erase the artificially drawn lines that often silo health at scales of persons (individuals), places (communities), and the planet at-large (biodiversity) [9]. The concept of planetary health seeks to address "Anthropocene Syndrome", the wicked interrelated challenges of our time. These include, but are not limited to, unacceptable poverty (of both income and opportunity), grotesque biodiversity losses, climate change, environmental degradation, resource depletion, the global burden of non-communicable diseases (NCDs), health inequalities, social injustices, the spread of ultra-processed foods, consumerism and incivility in tandem with a diminished emphasis on the greater potential of humankind, efforts toward unity, or the value of fulfilment and flourishing of all humankind [10]. Planetary health attempts to integrate the biological, psychological, social, and cultural aspects of health in the Anthropocene, and the urgent need to address these collectively across every level [11]. For completeness, we Like most Greek legends, the story of Narcissus has been used to teach generalized life lessons, particularly on the perils of selfishness. It also forms the basis of the term narcissism, used mostly to describe a personality trait characterized by elevated egocentrism, grandiosity, desire for attention, and diminished empathy. Here in this narrative review, we will explore the history and psychological science of narcissism in the context of planetary health. While much of scientific discourse on narcissism has focused on the diagnosable clinical personality disorder at the individual level, emerging research is examining temporal changes in narcissistic traits at larger scales [2], and the consequences of narcissism at collective levels among large groups [3].
Personality traits are often excluded from discussions of larger scale aspects of health and public policy because they are assumed to be mostly fixed over time and are frequently presented as descriptive summaries of behavior relevant to clinical settings [4]. Research, however, shows that personality traits are influenced by environmental factors and have dynamic aspects [5]; features of narcissism are not exempt from malleability [6,7].
Based on available evidence, it is our contention that narcissism, at scales ranging from the individual to the collective, is an oft-overlooked consideration in discussions of health along the continuum of person, place, and planet. Our discussion below is centered around the concept of planetary health which underscores that the health of human civilization cannot be uncoupled from the natural systems within the Earth's biosphere [8]; it has been defined as the interdependent vitality of all natural and anthropogenic ecosystems (social, political, and otherwise) and seeks to erase the artificially drawn lines that often silo health at scales of persons (individuals), places (communities), and the planet atlarge (biodiversity) [9]. The concept of planetary health seeks to address "Anthropocene Syndrome", the wicked interrelated challenges of our time. These include, but are not limited to, unacceptable poverty (of both income and opportunity), grotesque biodiversity losses, climate change, environmental degradation, resource depletion, the global burden of non-communicable diseases (NCDs), health inequalities, social injustices, the spread of ultra-processed foods, consumerism and incivility in tandem with a diminished emphasis on the greater potential of humankind, efforts toward unity, or the value of fulfilment and flourishing of all humankind [10]. Planetary health attempts to integrate the biological, psychological, social, and cultural aspects of health in the Anthropocene, and the urgent Challenges 2022, 13, 19 3 of 12 need to address these collectively across every level [11]. For completeness, we begin our discussion with the history of pathological narcissism; we include a brief discussion of narcissistic personality disorder, largely to distinguish personality traits and collective narcissism from what is currently defined as individual mental illness.

History of Pathological Narcissism
In addition to basic moral lessons, the myth of Narcissus has long-since been used to highlight that "vanity is an enemy of health" [12]. It has also been used to describe common personality traits among individuals. For example, Francis Bacon wrote that the Narcissus myth provides a descriptive for individuals who are "besotted with self-admiration" but are emotionally fragile in the business environment; Bacon argued that they prefer "a small circle of chosen companions, all devoted admirers", and despite sometimes being lauded early in life, eventually "lose all vigor and alacrity" and fade into obscurity [13].
The more specific observation that excessive self-adoration is a component of mental pathology dates back to the first attempts to scientifically categorize mental illness. For example, in 1852, pioneering psychiatrist Joseph Guislain (1797-1860) described the 'Narcissus mania' and differentiated it from melancholia and other forms of mania [14]. He noted that "there is a mania characterized by vanity, the mania of Narcissus . . . we behold the patient infatuated with his beauty, his charms, his wit, dress, talents, and birth" [15]. Guislain's observations are in line with contemporary observations on the symptomatic overlap between bipolar disorder and narcissistic personality disorder [16].
In 1898, English physician Havelock Ellis noted a "Narcissus-like tendency" of 'autoeroticism' in which persons with mental illness are "entirely lost in self-admiration" [17]; the following year, German criminologist Paul Näcke wrote an article supporting Ellis' case-reports of auto-eroticism, and added the 'ism' to coin the term 'narcissism' [18]. Ellis and Näcke focused on narcissism as a relatively rare sexual disorder, a perversion where the subject of immense attraction was the individual's own physical body [19].
In 1912, well-known author Herbert Kaufman used a larger lens. In a syndicated newspaper article, he wrote about individuals who have a "malady" of self-affection, persons that are "so anxious to be noticed" that they are unaware of the feelings of those around them. Kaufman argued that such individuals are a "menace in business" and in social relations because "vanity has bandaged [their] eyes". They are, he wrote, "a verbal Narcissus", infatuated with their own voice, and in the end suffer the loss of friendships [20]. Two years later, Sigmund Freud published his thesis On Narcissism. He postulated that primary narcissism (self-love) was a normal stage of childhood development; however, certain individuals, especially in cases of love expressed but unreciprocated by another, experience secondary narcissism in adulthood, wherein the libido (psychic energy associated with love, pleasure, and self-preservation) is turned inward [21]. Perhaps because Freud himself acknowledged that his theory of narcissism was not elaborate, and that he was disturbed "by its inadequacy", it was followed by decades of debate and scholarship within the psychoanalytic profession [22].
Throughout mid-20th century America the term 'narcissistic personality' was used to describe a wide variety of individuals, from dictators to Nobel prize winners, and in the realm of mental disorders, the term lacked specificity [23,24]. The path to formal diagnostic criteria began in 1973, when the American Psychiatric Association convened a task force to develop the Third Edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III) [25,26]. The new DSM would include a separate Axis, inclusive of personality disorders.
Throughout the seven-year span between the convening of the task force and the 1980 publication of the DSM-III, academic and lay press discussions of narcissistic personality, and narcissism in general, increased significantly; this was facilitated, at least in part by the media attention to Dr. Heinz Kohut, a University of Chicago psychiatrist who had been studying narcissism since 1957 [27,28]. Described as the "new Freud" by the Los Angeles Times, Kohut argued that narcissism is "the leading illness of our time", that lack of empathy is its hallmark, and that it was not the result of Freudian conflicts with sexual and aggressive drives, but rather social changes and shifting parental attention to children in the modern era [29,30]. The rise in Kohut's popularity was coincident with increasing challenges to Freudian theories as pseudoscience [31]. Kohut argued that beyond clinical psychiatry (he estimated that as many as 5-10% of patients in clinical settings had a narcissistic personality, and his followers suggested that it might be as much as 30% [29], narcissism was increasing in westernized society at-large. This view was shared by historian Christopher Lasch in his 1979 best-selling book Culture of Narcissism [32]. Narcissistic personality disorder was formally listed in the DSM-III, and for the most part, there has been little change in the diagnostic criteria compared to that found in the current DSM-V. In the DSM-III, "cool indifference or marked feelings of rage, inferiority, shame, humiliation, or emptiness in response to criticism" was listed as specific criteria, while in the DSM-V this has been removed and is now discussed only as "associated features supporting diagnosis". Currently, narcissistic personality disorder is defined as a pervasive pattern of grandiosity (fantasy or behavior), need for admiration, and a lack of empathy, beginning by early adulthood. Diagnosis is based on the presence of at least five of the following nine criteria in Table 1 [33]: Table 1. Criteria for narcissistic personality disorder (requires at least 5 criteria).

1.
Grandiose sense of self-importance (e.g., exaggerates achievements, expects to be recognized as superior without actually completing the achievements).

2.
Is preoccupied with fantasies of success, power, brilliance, beauty, or perfect love.

3.
Believes that they are special and unique, and can only be understood by or should only associate with other special people (or institutions).

5.
Has a sense of entitlement, such as an unreasonable expectation of favorable treatment or compliance with his or her expectations). 6.
Interpersonal exploitation, takes advantage of others to achieve their own ends. 7.
Lacks empathy; is unwilling to identify with the needs of others. 8.
Is often envious of others or believes that others are envious of them. 9.
Shows arrogant, haughty behaviors and attitudes.
Although not specifically diagnostic for narcissistic personality disorder, The Narcissistic Personality Inventory and the Pathological Narcissism Inventory are validated instruments used by researchers and clinicians to identify narcissistic traits that reflect the primary features of narcissistic personality disorder [34][35][36]. Clinicians have increasingly reported two types of narcissism-the grandiose type, which manifests as extreme confidence, audacity, and very high self-esteem, and the vulnerable type which manifests as low confidence, social avoidance, anxiety, and low self-esteem [37]. The classification of narcissistic personality as a specific disorder based on set criteria is controversial; it does not appear in the current International Classification of Diseases and its continued inclusion in the DSM-V was based on an 11th hour decision-some major news outlets even reported (prematurely) that it had been removed [38].
Available evidence makes it clear that individuals who meet the criteria and/or display high degrees of narcissistic traits are often distressed and suffering in life. Narcissism is associated with a higher risk of early mortality from physical disease (e.g., cardiovascular disease) and higher rates of suicide have been noted [39]. Those with the disorder have high rates of substance abuse, co-morbid mood and anxiety disorders, and often experience financial difficulties and workplace conflict [40]. In addition to distress to the sufferer, those in social circles of the individual and larger segments of society are impacted by narcissism [41].
Whether criteria-based narcissistic personality disorder is included in future editions of the DSM is a matter for committees within clinical psychology and psychiatry. Experts in the field have rightfully criticized the conflation of narcissistic personality disorder with the pejorative use of term 'narcissist' directed at individuals, or even entire generations [42].
Like all personality disorders, the former is characterized by clinically significant distress and/or dysfunction. It has become exceedingly common for media pundits and others to "diagnose" public figures with narcissistic personality disorder. However, as pointed out by Allen Frances, a psychiatrist who helped draft the DSM criteria, narcissistic traits are common to adults who are not mentally ill-"many, if not all politicians, and most celebrities" might qualify for a diagnosis of narcissistic personality disorder if the condition of clinically significant distress and/or impairment was ignored [43].
Our inclusion of narcissistic personality disorder in the discussion thus far is intended to provide perspective on a mental illness that is under the prevue of clinical psychiatry (and other mental health professions). Without the differentiation we run the risk of papering over suffering and unwittingly stigmatizing individuals with the disorder. It should also remove the inference that the ensuing discussion translates into psychiatry as the primary profession responsible for resolving the potential implications of large-scale narcissism and the shifting manifestation of narcissistic traits. Narcissism is a complex, multidimensional construct. For certain individuals, narcissistic traits may have financial and status benefits (e.g., rising to managerial or political positions even though they are not more qualified for the position [44]), and may even be positively associated with aspects of perceived wellness and meaning in life [45,46]. Our focus here is the ways in which narcissism, especially in the realms of policy and practices, and at the levers of power, can compromise health at all scales.

Narcissism beyond the Clinic-Universal Implications for Meaningful Progress
"Narcissus is unconscious of the cruelty that, by his thoughtlessness and selfishness, he is daily inflicting upon others. He recognizes no obligation to introduce into his sphere of action the broad principles of universal justice and humanity . . . [today] Narcissus is a too familiar character everywhere" John Herbert Phillips, Superintendent of Alabama Schools, 1905 [47].
Beyond the clinic and narrowly defined criteria, discussions of narcissistic traits are related to politics [48,49], business [50], sustainability [51], global security [52], human aggression [53], and public health [54,55]. Thus, like most aspects of human health and flourishing, narcissism encompasses virtually all branches of science and medicine. Given the broad implications, signals that large-scale (group-level) changes in narcissism can occur over time, the concept should be of high-level importance to the field of planetary health.
Although narcissism is not unique to westernized culture [56], there are signals from population studies in the United States and elsewhere, that narcissism (and/or traits associated with narcissism) has risen over time since the 1980s [57][58][59][60][61][62]. There are also emerging indicators that narcissistic traits among the population ebb and flow in concert with periods of economic growth (higher narcissism) and recession [2]; these shifts might also be intertwined with evolving relationships with social media (Figure 2) [63,64]. Even if temporal shifts in narcissism are moderate, when viewed along population scales, they can reflect an important consideration inside institutional and other social ecosystems that shape vitality, safety, and the variables of planetary health [65].
If a slightly larger percentage of society maintains high levels of self-importance, entitlement, and an admiration for social power, then there are obvious health repercussions to the group [66]. Since those with higher narcissistic traits are drawn to others with the same traits [67,68], and are less likely to find the signals of grandiosity and diminished empathy as repulsive [69], the implications along the health continuum of person, place, and planet are worth considering. For example, the allure of the narcissistic leader in politics and business may give the illusion of competence [70]; however, one of the primary features of grandiose narcissism is the over-estimation of intelligence and abilities, and once in leadership roles, dominant behavior and disregard for others can compromise the goals and vitality of the collective [71][72][73]. Since narcissism is associated with higher levels of conspicuous consumption (i.e., materialism directed at status symbols) [74], it is an important consideration in global marketing and consumerism that provides scaffolding to Anthropocene Syndrome [10,75,76] (Figure 3).
Challenges 2022, 13, x FOR PEER REVIEW 6 of 12 once in leadership roles, dominant behavior and disregard for others can compromise the goals and vitality of the collective [71][72][73]. Since narcissism is associated with higher levels of conspicuous consumption (i.e., materialism directed at status symbols) [74], it is an important consideration in global marketing and consumerism that provides scaffolding to Anthropocene Syndrome [10,75,76] (Figure 3).

Figure 2.
Population studies indicate a rise in narcissism (and/or traits associated with narcissism) over time and that these shifts might also be intertwined with evolving relationships with social media (artwork by author, S.L.P). In a distinct, but not unrelated line of investigation, international researchers are closely examining the concept of collective narcissism-belief in the greatness of a partic- Figure 2. Population studies indicate a rise in narcissism (and/or traits associated with narcissism) over time and that these shifts might also be intertwined with evolving relationships with social media (artwork by author, S.L.P).
Challenges 2022, 13, x FOR PEER REVIEW 6 of 12 once in leadership roles, dominant behavior and disregard for others can compromise the goals and vitality of the collective [71][72][73]. Since narcissism is associated with higher levels of conspicuous consumption (i.e., materialism directed at status symbols) [74], it is an important consideration in global marketing and consumerism that provides scaffolding to Anthropocene Syndrome [10,75,76] (Figure 3).

Figure 2.
Population studies indicate a rise in narcissism (and/or traits associated with narcissism) over time and that these shifts might also be intertwined with evolving relationships with social media (artwork by author, S.L.P). In a distinct, but not unrelated line of investigation, international researchers are closely examining the concept of collective narcissism-belief in the greatness of a partic- In a distinct, but not unrelated line of investigation, international researchers are closely examining the concept of collective narcissism-belief in the greatness of a particular ingroup, and that the particular in-group is not receiving adequate external recognition. The central features of collective narcissism include beliefs that the in-group is entitled to special treatment and privileges; it is also associated with hostility and resentment toward out-groups [77]. Thus, the concept of collective narcissism expands trait-based individual narcissism to the intergroup level. Just as the unrealistic beliefs held by the narcissistic individual are fragile, demanding continuous validation and a system of defense to protect the fragility, collective narcissism also describes similar emotional investments at larger scales [3,78]. For example, at the individual level narcissism may be associated with the superficial trappings of virtue, and at larger scales this can be observed with collective narcissism, such as support for superficial greenwashing efforts over actual green efforts that require deep levels of commitment [79]. Although high levels of individual narcissistic traits may or may not translate into higher collective narcissism (there are not enough cross-cultural studies including the Global South and diverse groups within populations to know with certainty), there are hints that among groups characterized by high-status and dominant international position, collective narcissism overlaps with the grandiose aspect of individual narcissism [80]. It is also worth pointing out that similar to high narcissism at the individual level, collective narcissism has been linked to stress-related health and psychosocial problems [81].
Beyond grandiosity, it is the absence of empathy that characterizes individual and collective narcissism that may be a critical threat to health at all scales. Empathy is the ability understand or make accurate inferences based on the experiences of another; the combined cognitive and emotional aspects of empathy allow one to take the perspective of another, and to experience some of their emotions in a vicarious way. In contrast to narcissism, empathy has been linked to life satisfaction, healthy and meaningful social networks, workplace performance, accommodative behavior, overall wellbeing, connection to nature, and pro-social activity [82][83][84]. Perhaps unsurprisingly, there are indications that large-scale population increases in narcissism are mirrored by declines in empathy [85,86].
At the individual level, antagonistic narcissism (i.e., the lens of rivalry, competition, and distrust) predicts lack of empathy for others [87]; low empathy appears to mediate the relationships between narcissism and reduced generosity, interpersonal conflict, and risk of criminality [88][89][90]. At the collective level, narcissism is associated with decreased empathy for marginalized groups [91]. While collective narcissism has received research attention, the concept of collective empathy is understudied [92][93][94]. Still, scholars are beginning to turn their attention to the ways in which collective empathy-as a product of the individuals who make up a collective, and their working core values-can be identified in groups and organizations [95].

Exiting the Anthropocene Requires Attention to Attitudes and Values
Since narcissism and empathy appear to be somewhat malleable, there is an urgent need for a better understanding of the ways in which both can be shaped at the individual and collective scales. Available evidence indicates that early childhood development is a critical period for the development of empathy and connectedness with nature [96]; in the context of planetary health, expansion of the knowledge base also requires further consideration of the 'dispositional empathy for nature' [97]. In what ways can we foster empathy for the biodiversity of non-human life that underpins the systems that sustain life, and in what ways can the negative influence of narcissism be minimized [98]?
Individual and collective attitudes and actions have been contributing to the pathology of Anthropocene Syndrome, and individual and collective actions will be required to usher on a new era. To this end, it is vital to understand how collective identities can contribute to the principles of planetary health [99] or detract from them [55,100,101]. Despite volumes of research on the health-related importance of early-life empathy development, replicated studies that can help guide an evidence-informed approach to increasing empathic concern remain scant [102]. At the same time, although it is becoming increasingly clear that collective narcissism is associated with attitudes and activities (e.g., social, economic, political) that discriminate against marginalized out-groups and increase the odds of unhealthy disparities, research directed at preventing or mitigating collective narcissism is limited. Preliminary research suggests that like individual narcissism, collective narcissism appears to be undergirded by negative emotionality. Therefore, cultivating non-narcissistic collective self-esteem and positive social identity is one potential solution [103].
In a recent expert position paper, personality scientists argued that the malleability of personality traits renders them actionable targets for research directed at policy changes and interventions [4]. Since major life events and environmental exposures have been linked to subsequent alterations in personality traits [104,105], and interventions have demonstrated that personality traits are malleable at the individual level [106,107], there is an urgent need to include personality features in research design. The authors state that the exclusion of personality traits from study protocols may be a product of "lack of imagination" on the part of researchers [4]. We agree, and point to the words of vaccine pioneer Jonas Salk, who also argued that there was not enough emphasis on pro-social personality traits and understanding they ways in which they are "evoked":"they need to be evoked...the challenge of evoking the best in us may seem utterly forbidding but, surely, no more so than previously "impossible" challenges-heavier-than-air-flight, electricity, space travel" [108].

Conclusions
"The most valuable members of future technological societies may turn out to be not those with the greatest ability to produce and distribute material goods but rather those who, through empathy and happiness, have the gift of spreading a spirit of good will" Rene Dubos, 1982 [109].
Anthropocene Syndrome involves a wide array of causative factors, many of them connected to a 'lifestyle' underpinned by attitudes, values, and behaviors held at scales ranging from individuals to large groups. Emerging research suggests that certain dispositions or 'traits'-observable on a continuum between the individual and groups, large and small-may be central to the promotion of health at scales of person, place, and planet. Despite a growing body of research directed at collective narcissism, and the role that empathy plays in healthy relationships between humans and nature, it is our contention that narcissism and empathy often escape discourse in the context of planetary health. The inclusion of personality traits in large-scale research endeavors should be considered a critical component of an evidence-informed passage out of the Anthropocene.

Conflicts of Interest:
The authors declare no conflict of interest.