At this early stage, patient is unable to differentiate his own feelings and needs from those of others. His cognitive and perceptual distortions and deficits (for instance, regarding his body image – known as a somatoform disorder) only increase his feeling of personal ineffectualness and his need to exercise even more self-control (by way of his diet).

The patient does not trust himself in slightest. He rightly considers himself to be his worst enemy, a mortal adversary. Therefore, any effort to collaborate with patient against his own disorder is perceived by patient as self-destructive. The patient is emotionally invested in his disorder - his vestigial mode of self-control.

The patient views world in terms of black and white, of absolutes ("splitting"). Thus, he cannot let go even to a very small degree. He is constantly anxious. This is why he finds it impossible to form relationships: he mistrusts (himself and by extension others), he does not want to become an adult, he does not enjoy sex or love (which both entail a modicum of loss of control).

All this leads to a chronic absence of self-esteem. These patients like their disorder. Their eating disorder is their only achievement. Otherwise they are ashamed of themselves and disgusted by their shortcomings (expressed through distaste with which they hold their body).

Eating disorders are amenable to treatment, though comorbidity with a personality disorder presages a poorer prognosis. The patient should be referred to talk therapy, medication, and enrol in online and offline support groups (such as Overeaters Anonymous).

Recovery prognosis is good after 2 years of treatment and support. The family must be heavily involved in therapeutic process. Family dynamics usually contribute to development of such disorders.

In short: medication, cognitive or behavioural therapy, psychodynamic therapy and family therapy ought to do it.

The change in patient following a successful course of treatment is VERY MARKED. His major depression disappears together with his sleeping disorders. He becomes socially active again and gets a life. His personality disorder might make it difficult for him – but, in isolation, without exacerbating circumstances of his other disorders, he finds it much easier to cope with.

Patients with eating disorders may be in mortal danger. Their behaviour is ruining their bodies relentlessly and inexorably. They might attempt suicide. They might do drugs. It is only a question of time. The therapist's goal is to buy them that time. The older they get, more experienced they become, more their body chemistry changes with age – better their chances to survive and thrive.

Sam Vaknin is the author of Malignant Self Love - Narcissism Revisited and After the Rain - How the West Lost the East. He is a columnist for Central Europe Review, PopMatters, and eBookWeb , a United Press International (UPI) Senior Business Correspondent, and the editor of mental health and Central East Europe categories in The Open Directory Bellaonline, and Suite101 .

Visit Sam's Web site at http://samvak.tripod.com

Confronting narcissist head on and engaging in power politics ("I am cleverer", "My will should prevail", and so on) is decidedly unhelpful and could lead to rage attacks and a deepening of narcissist's persecutory delusions, bred by his humiliation in therapeutic setting.

Successes have been reported by applying 12-step techniques (as modified for patients suffering from Antisocial Personality Disorder), and with treatment modalities as diverse as NLP (Neurolinguistic Programming), Schema Therapy, and EMDR (Eye Movement Desensitization).

But, whatever type of talk therapy, narcissist devalues therapist. His internal dialogue is: "I know best, I know it all, therapist is less intelligent than I, I can't afford top level therapists who are only ones qualified to treat me (as my equals, needless to say), I am actually a therapist myself…"

A litany of self-delusion and fantastic grandiosity (really, defences and resistances) ensues: "He (my therapist) should be my colleague, in certain respects it is he who should accept my professional authority, why won't he be my friend, after all I can use lingo (psycho-babble) even better than he does? It's us (him and me) against a hostile and ignorant world (shared psychosis, follies-a-deux)…"

Then there is this internal dialog: "Just who does he think he is, asking me all these questions? What are his professional credentials? I am a success and he is a nobody therapist in a dingy office, he is trying to negate my uniqueness, he is an authority figure, I hate him, I will show him, I will humiliate him, prove him ignorant, have his licence revoked (transference). Actually, he is pitiable, a zero, a failure…"

And this is only in first three sessions of therapy. This abusive internal exchange becomes more vituperative and pejorative as therapy progresses.

Narcissists generally are averse to being medicated. Resorting to medicines is an implied admission that something is wrong. Narcissists are control freaks and hate to be "under influence" of "mind altering" drugs prescribed to them by others.

Additionally, many of them believe that medication is "great equaliser" – it will make them lose their uniqueness, superiority and so on. That is unless they can convincingly present act of taking their medicines as "heroism", a daring enterprise of self-exploration, part of a breakthrough clinical trial, and so on.

They often claim that medicine affects them differently than it does other people, or that they have discovered a new, exciting way of using it, or that they are part of someone's (usually themselves) learning curve ("part of a new approach to dosage", "part of a new cocktail which holds great promise"). Narcissists must dramatise their lives to feel worthy and special. Aut nihil aut unique – either be special or don't be at all. Narcissists are drama queens.

Very much like in physical world, change is brought about only through incredible powers of torsion and breakage. Only when narcissist's elasticity gives way, only when he is wounded by his own intransigence – only then is there hope.

It takes nothing less than a real crisis. Ennui is not enough.

Sam Vaknin is the author of Malignant Self Love - Narcissism Revisited and After the Rain - How the West Lost the East. He is a columnist for Central Europe Review, PopMatters, and eBookWeb , a United Press International (UPI) Senior Business Correspondent, and the editor of mental health and Central East Europe categories in The Open Directory Bellaonline, and Suite101 .

Visit Sam's Web site at http://samvak.tripod.com