The Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 personality disorder committee has decided to reinstate NPD in the latest proposal for the personality disorder section of June 2011 . Although not yet finalized, this most sensible decision to acknowledge the significance of NPD has major beneficial consequences. Accumulating theoretical, clinical and empirical studies on pathological narcissism and NPD can stimulate further research and improve the diagnosis and understanding of this complex condition. Clinicians will have a more useful guideline for identifying and treating people with this disordered personality functioning. The proposed dual approach applied to diagnosing personality disorders includes both a dimensional section outlining impairments in personality functioning and a section with pathological personality traits. The basic rationale for this new approach to diagnosing personality disorders was to increase the clinical utility by including representations of both self and others, and by outlining degree of severity of impairment in personality functioning. Acknowledging the extensive literature on mental representation, in particular on internalized self–other interactional patterns and the distortions in perceptions and thoughts about self and others, separately as well as in interactions, represents a radical step forward in diagnosing personality disorder [2▪,3▪].
This approach encourages a more dynamic diagnostic formulation that can incorporate both regulatory processes and fluctuations within each area of functioning. This is an important advantage for NPD as the exclusively trait-focused diagnostic approach failed to meaningfully identify especially the range of degree and complexity in narcissistic functioning.
NARCISSISTIC PERSONALITY DISORDERS IN DSM 5: A NEW APPROACH
The new proposed diagnostic outline of NPD in DSM 5  attends to the characteristics in identity that are either driven by or reflected in shifts in sense of self, self-evaluation and self-esteem with accompanying fluctuations in emotions. Self-direction – a central component in self-agency – is a very relevant dimension as narcissistic personality functioning and self-esteem closely relate to the individual's evaluation of competence, achievements, assets and affiliation as well as to perfectionism and ideal standards. Recognizing empathy as a capability with deficiencies and areas or moments of fluctuations, a major step forward in the overall DSM 5 personality disorder proposal, contrasts with the ‘black/white’ and ‘absent/present’ trait approach applied in the previous DSM manuals [4–6]. This integrates relevant neuroscientific research [7,8▪▪] that identifies separate interactive functional components affecting empathic ability, such as emotion recognition and comprehension, attunement to emotional experiences in both self and others, and self-esteem regulation. Interpersonal functioning is also guided by self-esteem regulation and influenced by efforts to enhance the self and reach personal gains. Two pathological personality traits were transferred from DSM IV, grandiosity and attention seeking. The former is now defined in terms of entitlement, self-centeredness and condescending attitude, whereas the latter remains similar to DSM IV and captures admiring attention.
COMPARISON OF NARCISSISTIC PERSONALITY DISORDER IN DSM IV AND DSM 5
As pointed out by Morey and Stagner [9▪▪] in an informative review of the history of NPD in DSM, a major difficulty when introducing NPD in DSM III in 1980 was to transform psychoanalytically based observations of pathological narcissism into a set of trait-based diagnostic criteria for NPD. This problem has remained throughout the past three decades, foremost reflected in the difficulties in reaching a consensus between empirically and clinically based diagnosis of NPD. The authors point to a convergence between psychoanalytic/ psychodynamic and purely diagnostic conceptualizations of NPD in the latest proposal of DSM 5. The general conceptualization of pathological narcissism in the initial DSM 5 outline, especially the choice of self-direction, identity and empathic functioning, includes aspects of narcissistic self-regulation common to most personality disorders. The shift from the previously one-sided emphasis on grandiosity to recognizing impairment and fluctuations in self-regulation and emotion regulation is a most constructive step forward and more representative of narcissistic pathology [10▪▪]. As is pointed out by Morey and Stagner [9▪▪] in their clinical vignette, the new DSM 5 proposal invites a much more encompassing evaluation of the range and level of impairment of pathological narcissism, from a self and other perspective with accompanying emotional functioning.
The new diagnostic approach has implications for treatment planning. As the authors point out: ‘Under the DSM IV the clinician will typically select a personality disorder construct and formulate treatment based upon that concept’ ([9▪▪], p. 915). In DSM 5, on the contrary, the focus is on pathology in self and other representations and how these deficits can be expressed. This approach explicitly directs the clinicians’ attention towards the patient's regulatory functioning, range of and fluctuations in deficits and the various levels of severity of pathology within the different domains and facets. This is important not only for conceptualization of personality disorder functioning and definition, but also for choice of treatment modality or modalities, and for understanding and predicting progression in treatment. With regards to NPD, a major advantage is that this diagnostic approach allows identifying phenotypes of NPD, and especially grandiose and vulnerable aspects of pathological narcissism .
The proposed format for diagnosing NPD in DSM 5 has several advantages, besides the endorsement of a regulatory and dynamic approach to the diagnostic assessment and formulation of NPD. Conceptualizations and research on self-regulation and self-esteem regulation, perfectionism, agency and empathic functioning and emotion regulation, all of relevance for NPD, can now be incorporated and applied to the diagnosis of NPD. It uses a descriptive language that is less biased, pejorative and provocative, and more clinically informative for identifying and describing pathological narcissism. This is most important for alliance building and for reaching agreements between patient and clinician on indicators for pathological narcissism and NPD. The diagnosis can capture a broader range of functional, phenotypic and clinical presentation of NPD, as well as the more specific fluctuations and variability in pathological narcissistic functioning. It is in many ways more closely related to and able to reflect functional patterns and features highlighted in the extensive clinical literature on narcissism and NPD.
There are additional dynamic and motivational aspects of pathological narcissism with diagnostic relevance that are not fully captured in the DSM 5 proposal. One concerns the narcissistic individual's unintegrated and shifting sense of self. People with pathological narcissism and NPD tend to have a complex internal self-evaluation, and be excessively self-critical and judgmental underneath a more noticeable self-praising or self-enhancing presentation. Another is their intense reaction to perceived threats to self-esteem, such as humiliation, defeats, criticism, failures, or envy from others. Such reactions can include intense feelings (overt or covert anger/hostility, envy or shame or fear), mood shifts (irritability, anxiety, depression or elation), or deceitful or retaliating behavior (aggressive, antisocial or suicidal behavior). Reactivity is reflected in fluctuations in self-esteem that can alternate between states of overconfidence, superiority and assertiveness and states of inferiority, insecurity and incompetence (grandiosity and vulnerability). In addition to their unawareness of their own motivations, people with NPD can also present with compromised sense of identity and often not know who they are. Their sense of self-agency is influenced by need for internal control, sense of self-sufficiency and avoidance of threats or challenges to self-esteem, with reluctance or inability to rely on others. People with NPD can be both vulnerable and insensitive to others’ feedback and input for self-definition. Being self-enhanced and self-preoccupied serve as a protective armor, to shield or hide low self-esteem, harsh self-criticism, insecurity, inferiority, shame, loneliness, detachment and fear.
Grandiosity-promoting strivings and activities include superiority and fantasies of self-fulfillment, perfectionism and high ideals, as well as self-enhancing and self-serving interpersonal behavior. Grandiosity is state dependent and fluctuating, and the diagnosis of NPD should not rely on indications of grandiose self-experience or superiority . Although people with NPD can have a range of dynamic, cognitive, emotional and interpersonal ways to sustain and enhance grandiosity, they are also extremely sensitive to criticism and failures as well as to self-directed aggression, self-doubts, shame and fear [10▪▪]. Sudden suicidality in response to subjectively perceived overwhelming failures or losses can occur .
The efforts to narrow down the identifiers of NPD into psychiatric traits and diagnostic criteria tend to bypass the fact that real life experiences and functioning can be most influential on narcissistic functioning . Narcissism ranges from healthy and proactive to pathological and malignant. Consequently, pathological narcissism and NPD often co-occur with consistent or intermittent areas or periods of high functioning , associated with a sense of agency and competence, or, alternatively, with more specific actual qualities, capabilities, or social skills. Changes towards worsening as well as improvement in narcissistic functioning often relate to real life experiences that in various ways can be either threatening and corrosive or corrective and promoting . For example, as Magidson et al.[16▪▪] point out, facing a medical condition that enforces interaction with medical settings and experts can drastically unfold a range of intense pathological narcissistic reactions in individuals with vulnerable narcissism or NPD that disrupt interactions with providers and obstruct optimal treatment and recovery. In these situations, it would be beneficial if the medical providers could be able to engage the patient in identifying narcissistic symptoms or indications of NPD and recommend psychiatric evaluation or psychotherapy. Similarly, developmental life changes (marriage, childbirth and rearing, retirement and aging) as well as sudden unexpected life events in professional, financial or interpersonal contexts can drastically impact people with narcissistic vulnerability. Awareness and knowledge about pathological narcissistic functioning and NPD can be useful and even crucial, not only in psychological/psychiatric treatment settings, but also in medical settings and in organizations and workplaces as well.
OBSERVERS’ VERSUS PATIENTS’ PERCEPTION OF NARCISSISTIC PERSONALITY DISORDER
A recent study by Cooper et al.[17▪▪] highlights the problems with narcissistic patients’ ability to report and assess indicators of pathological narcissism. They found self-reported prevalence of NPD in a community sample to be 4% compared with 11% informant-reported and 14% self–informant combined, that is, a 2.5 times increase in NPD prevalence based on informants’ observations. This compares with the estimated prevalence of NPD in epidemiological studies of general population that range from 0.0% to 6.25% (7.7% for men and 4.8% for women) , and in clinical population (1.3–17%) and outpatient private practice (8.5–20%) (see ). Cooper et al. found low to nonsignificant patient–informant agreement with regards to both NPD criteria and diagnosis. Informants tend to report more features of pathological narcissism and on a lower level of NPD pathology than patients, indicating that they are more sensitive and able to detect and report less severe or even subtle levels of pathological narcissism. They also pay more attention to certain criteria, such as grandiose sense of self-importance, entitlement and arrogance. Patients, on the contrary, report fewer NPD criteria especially at the higher end of the NPD scale (increased severity), but tend to identify a higher level of pathological narcissism, that is, they tend to ignore indications of pathological narcissism until it is relatively severe, in particular exploitativeness and feelings of envy. In addition, patients’ and informants’ reports tend to increasingly diverge with severity of NPD. The authors suggest that individuals with NPD may not think the criteria apply to them, or neglect to endorse socially undesirable features.
This interesting study has several implications. First, it supports the general notion that people with pathological narcissism tend to provide self-reports, especially when they feel on the stand, evaluated or critically judged, that are influenced by their defensive strategies and perceptual limitation, such as denial, self-enhancement, perfectionism, shame, and control.
Second, it supports noted discrepancies between narcissistic individuals’ external behavior and presentation and their internal, subjective experiences. Patients with NPD externally and interpersonally often present themselves in ways that differ from how they subjectively perceive themselves and their internal feelings and experience. The DSM IV trait-focused approach automatically tends to evoke defensive responses because it failed to reach a meaningful correspondence with the patient's individual subjective correlates and experiences. Grandiose sense of self-importance correlates with the individual's usually hidden feelings of uncertainty and insecurity. Grandiose fantasies may be veiled beneath a seemingly selfless, timid or ingratiating attitude. Similarly, arrogance, belief in being special and seeking admiration can be spurred by a sense of inadequacy or by fear of failure, injury or loss of control and competence with accompanying need for reassurance from outside. Excessive entitlement is usually tied to its opposite, feeling undeserving, and envy of others can be mixed up with fear of others’ envy .
Third, it supports the need for an alternative diagnostic approach to pathological narcissism and NPD that can engage the patient in a collaborative exploratory diagnostic process and promote self-reflection and self-observations [21▪▪]. It calls for a diagnostic strategy that can connect and integrate different perspectives, that is, the clinician's observations of the patient's external and interpersonal behavior and attitudes, and the patient's accounts of his/her subjective experiences of self and others in social and interpersonal interactions.
The new diagnostic approach to NPD in DSM 5 captures more clinically relevant psychological features of pathological narcissism and NPD beyond grandiosity and the immediate external functioning. It has the potential to promote a diagnostic strategy that can take into consideration the fact that some aspects of narcissistic pathology are more externally noticeable and less attended to or even hidden from the narcissistic patient's attention and willingness or capability to identify, whereas others are more readily identified by the patient himself/herself and maybe less so by others. The DSM 5 diagnostic approach can encourage a collaborative exploratory diagnostic process. Such an approach differs markedly from a sole clinician-based diagnosis that is based on notable external and provocative narcissistic personality traits, foremost grandiosity, as outlined in DSM IV. For a diagnosis to be meaningful, informative and function as an incentive and motivation for treatment, the patient has to be engaged and find that a diagnostic facet makes sense and corresponds to his/her own experiences and suffering. More observations and studies are called for that can bridge the gap between narcissistic patients’ subjective experiences and understanding of their problems and symptoms, and others’, including the clinicians’, observations of external indicators of pathological narcissism.
This article was written before the APA's final last minute decision concerning the diagnosis and classification of Personality disorders in DSM-5.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 131–132).
2▪. Bender DS, Morey LC, Skodol AW. Toward a model for assessing level of personality functioning in DSM-5, Part I: Review of theory and methods. J Pers Assess 2011; 93:332–346.
The introduction of a continuum of personality functioning with different levels makes it possible to integrate the personality functioning in people with NPD, which can range from high and competent to low with severe social impairment and comorbid mental disorders.
3▪. Skodol AW, Clark LA, Bender DS, et al. Proposed changes in personality and personality disorder assessment and diagnosis
for DSM-5 part 1: Description and rationale. Pers Disord 2011; 2:4–22.
This article provides a thorough account of the new conceptualization of personality disorder proposed in DSM 5, including pathological personality functioning, traits and types. Note that some changes have been made since this article was published.
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: Author 1980.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: Author 1994.
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text Revision. Washington, DC: Author 2000.
7. Decety J, Jackson PL. The functional architecture of human empathy. Behav Cognitive Neurosci Rev 2004; 3:71–100.
8▪▪. Ritter K, Dziobek I, Preißler S, et al. Lack of empathy in patients with narcissistic personality disorder
. Psychiatry Res 2011; 187:241–247.
This first exploration of empathic functioning in patients with NPD focused on emotional and cognitive empathy. Results suggest deficits in emotional empathic capability and intact cognitive empathic functioning in NPD. The authors encouraged a multidimensional assessment of empathy in NPD and reformulation of the corresponding DSM diagnostic criteria.
9▪▪. Morey LC, Stagner BH. Narcissistic pathology as core personality dysfunction: comparison of DSM-IV and the DSM-5 proposal for narcissistic personality disorder
. J Clin Psychol 2012; 68:908–921.
This review article compares the diagnosis of pathological narcissism and NPD in DSM-IV and DSM 5 and it also includes a case study that applies the strategies and shows the advantages of a dimensional as opposite to exclusive trait approach.
10▪▪. Pincus A. Some comments on nomology, diagnostic process, and narcissistic personality disorder
in the DSM-5 proposal for personality and personality disorders. Pers Disord 2011; 2:41–53.
In this commentary on the DSM 5 proposal for personality disorders, the author attends to some of the central issues with regards to research and diagnosis of NPD, construct definition and validity. The difference between grandiose and vulnerable characteristics of NPD with regards to clinical and treatment utility is also discussed.
11. Pincus AL, Lukowitsky MR. Pathological narcissism
and narcissistic personality disorder
. Ann Rev Clin Psychol 2010; 6:421–446.
12. Ronningstam E, Gunderson J, Lyons M. Changes in pathological narcissism
. Am J Psychiatry 1995; 152:253–257.
13. Ronningstam E, Weinberg I, Maltsberger J. Eleven deaths of Mr. K: contributing factors to suicide in narcissistic personalities. Psychiatry 2008; 71:169–182.
14. Blais MA, Little JA. Toward an integrative study of narcissism
. Pers Disord 2010; 1:197–199.
15. Russ E, Shedler J, Bradley R, Westen D. Refining the construct of narcissistic personality disorder
: diagnostic criteria and subtypes. Am J Psychiatry 2008; 165:1473–1481.
16▪▪. Magidson JF, Collado-Rodriguez A, Madan A, et al. Addressing narcissistic personality features in the context of medical care: Integrating diverse perspectives to inform clinical practice. Pers Disord 2012; 3:196–208.
This practice review with case examples describing patients with NPD in the medical setting provides valuable perspectives on narcissistic reactivity and the difficulties of motivating and negotiating necessary treatment. It is a ‘real-life’ account of pathological narcissistic function in people with medical conditions seeking and facing medical treatment. The discussion of various ways to approach these problems is informative.
17▪▪. Cooper LD, Balsis S, Oltmans TF. Self- and informant-reported perspectives on symptoms of narcissistic personality disorder
. Pers Disord 2012; 3:1–15.
This study highlights the discrepancies between informants’ and patients’ reports of pathological narcissism. The fact that outside observers perceive and report on pathological narcissism in a different way than the patient with such a condition has implications for the diagnostic process and for outlining a more appropriate diagnostic strategy.
18. Stinson FS, Dawson DA, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder
: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2008; 69:1033–1045.
19. Ronningstam E. Narcissistic personality disorder
: facing DSM-V. Psychiatric Ann 2009; 39:111–121.
20. Ronningstam E, Maltsberger J. Treatment of narcissistic personality disorder
. In: Gabbard G, editor. Treatment of psychiatric disorders. 4th ed. Washington DC: American Psychiatric Press, Inc.; 2007. pp. 791–804.
21▪▪. Ronningstam E. Alliance building and the diagnosis
of narcissistic personality disorder
. J Clin Psychol 2012; 68:941–953.