Narcissistic Personality Disorder (NPD) : DSM-IV Diagnostic Criteria

Introduction | What is a personality disorder? | Narcissistic Personality Disorder How to recognize a narcissist | Traits discussed | "Now We Are Six" | "It's a Good Life" What's normal? | Further reading | Attachment | Narcissus in art | Aftermath | Beyond | Music

What is a personality disorder?

[from Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 1994, commonly referred to as DSM-IV, of the American Psychiatric Association. European countries use the diagnostic criteria of the World Health Organization.]

An enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. A personality disorder is a pattern of deviant or abnormal behavior that the person doesn't change even though it causes emotional upsets and trouble with other people at work and in personal relationships. It is not limited to episodes of mental illness, and it is not caused by drug or alcohol use, head injury, or illness. There are about a dozen different behavior patterns classified as personality disorders by DSM-IV. All the personality disorders show up as deviations from normal in one or more of the following: (1) cognition -- i.e., perception, thinking, and interpretation of oneself, other people, and events; (2) affectivity -- i.e., emotional responses (range, intensity, lability, appropriateness); (3) interpersonal functions; (4) impulsivity.

Narcissistic Personality Disorder

While grandiosity is the diagnostic hallmark of pathological narcissism, there is research evidence that pathological narcissism occurs in two forms, (a) a grandiose state of mind in young adults that can be corrected by life experiences, and (b) the stable disorder described in DSM-IV, which is defined less by grandiosity than by severely disturbed interpersonal relations. The preferred theory seems to be that narcissism is caused by very early affective deprivation, yet the clinical material tends to describe narcissists as unwilling rather than unable, thus treating narcissistic behaviors as volitional -- that is, narcissism is termed a personality disorder, but it tends to be discussed as a character disorder. This distinction is important to prognosis and treatment possibilities. If NPD is caused by infantile damage and consequent developmental short-circuits, it probably represents an irremediable condition. On the other hand, if narcissism is a behavior pattern that's learned, then there is some hope, however tenuous, that it's a behavior pattern that can be unlearned. The clinical literature on NPD is highly theoretical, abstract, and general, with sparse case material, suggesting that clinical writers have little experience with narcissism in the flesh. There are several reasons for this to be so: -- The incidence of NPD is estimated at 1% in the general population, though I haven't been able to discover the basis of this estimate. -- Narcissists rarely enter treatment and, once in treatment, progress very slowly. We're talking about two or more years of frequent sessions before the narcissist can acknowledge even that the therapist is sometimes helpful. It's difficult to keep narcissists in treatment long enough for improvement to be made -- and few people, narcissists or not, have the motivation or the money to pursue treatment that produces so little so late. -- Because of the influence of third-party payers (insurance companies), there has been a strong trend towards short-term therapy that concentrates on ameliorating acute troubles, such as depression, rather than delving into underlying chronic problems. Narcissists are very reluctant to open up and trust, so it's possible that their NPD is not even recognized by therapists in shortterm treatment. Purely anecdotal evidence from correspondents and from observations of people I know indicates that selective serotonin-reuptake inhibitors, such as Prozac, aggravate narcissists' grandiosity and lack of social inhibition. It has also been suggested that self-help literature about bolstering self-esteem and getting what you want out of life or that encourages the feeling of victimization has aggravating effects on NPD thinking and behavior. -- Most clinical writers seem unaware that narcissists' self-reports are unreliable. This is troubling, considering that lying is the most common complaint about narcissists and that, in many instances, defects of empathy lead narcissists to wildly inaccurate misinterpretations of other people's speech and actions, so that they may believe that they are liked and respected despite a history of callous and exploitative personal interactions.
[from Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 1994, commonly referred to as DSM-IV, of the American Psychiatric Association. European countries use the diagnostic criteria of the World Health Organization.]

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.[jma: NPD first appeared in DSM-III in 1980; before that time there had been no formal diagnostic description. Additionally, there is considerable overlap between personality disorders and clinicians tend to diagnose mixes of two or more. Grandiosity is a special case, but lack of empathy and exploitative interpersonal relations are not unique to NPD, nor is the need to be seen as special or unique. The differential diagnosis of NPD is made on the absence of specific gross behaviors. Borderline Personality Disorder has several conspicuous similarities to NPD, but BPD is characterized by self-injury and threatened or attempted suicide, whereas narcissists are rarely self-harming in this way. BPD may include psychotic breaks, and these are uncharacteristic of NPD but not unknown. The need for constant attention is also found in Histrionic Personality Disorder, but HPD and BPD are both strongly oriented towards relationships, whereas NPD is characterized by aloofness and avoidance of intimacy. Grandiosity is unique to NPD among personality disorders, but it is found in other psychiatric illnesses. Psychopaths display pathological narcissism, including grandiosity, but psychopathy is differentiated from NPD by psychopaths' willingness to use physical violence to get what they want, whereas narcissists rarely commit crimes; the narcissists I've known personally are, in fact, averse to physical contact with others, though they will occasionally strike out in an impulse of rage. It has been found that court-ordered psychotherapy for psychopaths actually increases their recidivism rate; apparently treatment teaches psychopaths new ways to exploit other people. Bipolar illness also contains strong elements of grandiosity. See more on grandiosity and empathy and its lack below.]The disorder begins by early adulthood and is indicated by at least five of the following: Translation: Narcissistic Personality Disorder (NPD) is a pattern of self-centered or egotistical behavior that shows up in thinking and behavior in a lot of different situations and activities. People with NPD won't (or can't) change their behavior even when it causes problems at work or when other people complain about the way they act, or when their behavior causes a lot of emotional distress to others (or themselves? none of my narcissists ever admit to being distressed by their own behavior -- they always blame other people for any problems). This pattern of self-centered or egotistical behavior is not caused by current drug or alcohol use, head injury, acute psychotic episodes, or any other illness, but has been going on steadily at least since adolescence or early adulthood. NPD interferes with people's functioning in their occupations and in their relationships: Mild impairment when self-centered or egotistical behavior results in occasional minor problems, but the person is generally doing pretty well. Moderate impairment when self-centered or egotistical behavior results in: (a) missing days from work, household duties, or school, (b) significant performance problems as a wageearner, homemaker, or student, (c) frequently avoiding or alienating friends, (d) significant risk of harming self or others (frequent suicidal preoccupation; often neglecting family, or frequently abusing others or committing criminal acts). Severe impairment when self-centered or egotistical behavior results in: (a) staying in bed all day, (b) totally alienating all friends and family, (c) severe risk of harming self or others (failing to maintain personal hygiene; persistent danger of suicide, abuse, or crime). 1. An exaggerated sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) Translation: Grandiosity is the hallmark of narcissism. So what is grandiose? The simplest everyday way that narcissists show their exaggerated sense of self-importance is by talking about family, work, life in general as if there is nobody else in the picture. Whatever they may be doing, in their own view, they are the star, and they give the impression that they are bearing heroic responsibility for their family or department or company, that they have to take care of everything because their spouses or co-workers are undependable, uncooperative, or otherwise unfit. They ignore or denigrate the abilities and contributions of others and complain that they receive no help at all; they may inspire your sympathy or admiration for their stoicism in the face of hardship or unstinting self-sacrifice for the good of (undeserving) others. But this everyday grandiosity is an aspect of narcissism that you may never catch on to unless you visit the narcissist's home or workplace and see for yourself that others are involved and are pulling their share of the load and, more often than not, are also pulling the narcissist's share as well. An example is the older woman who told me with a sigh that she knew she hadn't been a perfect mother but she just never had any help at all -- and she said this despite knowing that I knew that she had worn out and discarded two devoted husbands and had lived in her parents' pocket (and pocketbook) as long as they lived, quickly blowing her substantial inheritance on flaky business schemes. Another example is claiming unusual benefits or spectacular results from ordinary effort and investment, giving the impression that somehow the narcissist's time and money are worth more than other people's. [Here is an article about recognizing and coping with narcissism in the workplace; it is rather heavy on management jargon and psychobabble, but worth reading. "The Impact of Narcissism on Leadership and Sustainability" by Bruce Gregory, Ph.D. "When the narcissistic defense is operating in an interpersonal or group setting, the grandiose part does not show its face in public. In public it presents a front of patience, congeniality, and confident reasonableness."] In popular usage, the terms narcissism, narcissist, and narcissistic denote absurd vanity and are applied to people whose ambitions and aspirations are much grander than their evident talents. Sometimes these terms are applied to people who are simply full of themselves -- even when their real achievements are spectacular. Outstanding performers are not always modest, but they aren't grandiose if their self-assessments are realistic; e.g., Muhammad Ali, then Cassius Clay, was notorious for boasting "I am the greatest!" and also pointing out that he was the prettiest, but he was the greatest and the prettiest for a number of years, so his selfassessments weren't grandiose. Some narcissists are flamboyantly boastful and selfaggrandizing, but many are inconspicuous in public, saving their conceit and autocratic opinions for their nearest and dearest. Common conspicuous grandiose behaviors include expecting special treatment or admiration on the basis of claiming (a) to know important, powerful or famous people or (b) to be extraordinarily intelligent or talented. As a real-life example, I used to have a neighbor who told his wife that he was the youngest person since Sir Isaac Newton to take a doctorate at Oxford. The neighbor gave no evidence of a world-class education, so I looked up Newton and found out that Newton had completed his baccalaureate at the age of twenty-two (like most people) and spent his entire academic career at Cambridge. The grandiose claims of narcissists are superficially plausible fabrications, readily punctured by a little critical consideration. The test is performance: do they deliver the goods? (There's also the special situation of a genius who's also strongly narcissistic, as perhaps Frank Lloyd Wright. Just remind yourself that the odds are that you'll meet at least 1000 narcissists for every genius you come across.) [More on grandiosity.]

2. Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love Translation: Narcissists cultivate solipsistic or "autistic" fantasies, which is to say that they live in their own little worlds (and react with affront when reality dares to intrude). 3. Believes he is "special" and can only be understood by, or should associate with, other special or high-status people (or institutions) Translation: Narcissists think that everyone who is not special and superior is worthless. By definition, normal, ordinary, and average aren't special and superior, and so, to narcissists, they are worthless. 4. Requires excessive admiration Translation: Excessive in two ways: they want praise, compliments, deference, and expressions of envy all the time, and they want to be told that everything they do is better than what others can do. Sincerity is not an issue here; all that matter are frequency and volume. 5. Has a sense of entitlement Translation: They expect automatic compliance with their wishes or especially favorable treatment, such as thinking that they should always be able to go first and that other people should stop whatever they're doing to do what the narcissists want, and may react with hurt or rage when these expectations are frustrated. 6. Selfishly takes advantage of others to achieve his own ends

Translation: Narcissists use other people to get what they want without caring about the cost to the other people. 7. Lacks empathy Translation: They are unwilling to recognize or sympathize with other people's feelings and needs. They "tune out" when other people want to talk about their own problems. In clinical terms, empathy is the ability to recognize and interpret other people's emotions. Lack of empathy may take two different directions: (a) accurate interpretation of others' emotions with no concern for others' distress, which is characteristic of psychopaths; and (b) the inability to recognize and accurately interpret other people's emotions, which is the NPD style. This second form of defective empathy may (rarely) go so far as alexithymia, or no words for emotions, and is found with psychosomatic illnesses, i.e., medical conditions in which emotion is experienced somatically rather than psychically. People with personality disorders don't have the normal body-ego identification and regard their bodies only instrumentally, i.e., as tools to use to get what they want, or, in bad states, as torture chambers that inflict on them meaningless suffering. Self-described narcissists who've written to me say that they are aware that their feelings are different from other people's, mostly that they feel less, both in strength and variety (and which the narcissists interpret as evidence of their own superiority); some narcissists report "numbness" and the inability to perceive meaning in other people's emotions. 8. Is often envious of others or believes that others are envious of him Translation: No translation needed. 9. Shows arrogant, haughty, patronizing, or contemptuous behaviors or attitudes

Translation: They treat other people like dirt.

[Some descriptions and explanations on this page are based on material from What is a personality disorder? by Paul J. Hannig, Ph.D., The Online Journal of Psychiatry, Narcissistic Personality Disorder, and (defunct) Internet Mental Health questionnaire for diagnosis of Narcissistic Personality Disorder. For a firsthand account of what it's like to have NPD, see "Malignant SelfLove - Narcissism Re-visited" by Shmuel (Sam) Vaknin, Ph.D.]

Introduction | What is a personality disorder? | Narcissistic Personality Disorder How to recognize a narcissist | Traits discussed | "Now We Are Six" | "It's a Good Life" What's normal? | Further reading | Attachment | Narcissus in art | Aftermath | Beyond | Music

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1998-2004 by Joanna M. Ashmun.

http://www.halcyon.com/jmashmun/npd/dsm-iv.html18.04.2009 18:08:31