Narcissism and Narcissistic Abuse in Relationships (Part XIII)

Diagnosis

DSM-5

The American Psychiatric Association's (APA) formulation, description, and definition of narcissistic personality disorder, as published in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed., Text Revision (DSM-IV-TR, 2000), was criticized by clinicians as inadequately describing the range and complexity of the personality disorder that is NPD. That the APA's formulation, description, and definition is excessively focused upon "the narcissistic individual's external, symptomatic, or social interpersonal patterns – at the expense of . . . internal complexity and individual suffering", which reduced the clinical utility of the NPD definition in the DSM-IV-TR.

In revising the diagnostic criteria for personality disorders, the work group for the list of "Personality and Personality Disorders" proposed the elimination of narcissistic personality disorder (NPD) as a distinct entry in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Ed. (DSM-5, 2013), and thus replaced a categorical approach to NPD with a dimensional approach, which is based upon the severity of the dysfunctional-personality-trait domains.  Clinicians critical of the DSM-5 revision characterized the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist", which is of limited usefulness in clinical practice.  Despite the reintroduction of the NPD entry, the APA's re-formulation, re-description, and re-definition of NPD, towards a dimensional view based upon personality traits, remains in the list of personality disorders of the DSM-5.

ICD-10

The International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), of the World Health Organization (WHO), lists narcissistic personality disorder (NPD) under the category of "Other specific personality disorders". The ICD-10 requires that any personality-disorder diagnosis also meet and satisfy the General diagnostic criteria 2 used for determining that a person has a diagnosable personality disorder.

Subtypes of NPD

Although the DSM-5 indicates narcissistic personality disorder as a homogeneous syndrome, there is evidence of overt and covert subtypes in the expression of NPD. The study Narcissistic Personality Disorder: Diagnostic and Clinical Challenges (2015) indicates the existence of two subtypes of narcissism: (i) Grandiose narcissism, characterized by the personality traits of grandiosity, arrogance, and boldness; and (ii) Vulnerable narcissism, characterized by the personality traits of defensiveness and hypersensitivity.  The research indicates that people with grandiose narcissism express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism."

In an inventory of the types of NPD, the psychiatrist Glen Gabbard described the "oblivious" subtype of narcissist as being a grandiose, arrogant, and thick-skinned person; and described the "narcissistic vulnerability" of the subtype of person who consciously exhibits the personality traits of helplessness and emotional emptiness, and of low self-esteem and shame, which usually are expressed as socially avoidant behavior in situations where the narcissist's self-presentation is impossible; therefore, they withdraw from situations wherein the needed or expected social approval is not given.  Gabbard also described the "hypervigilant" subtype of narcissist whose feelings are easily hurt, has an oversensitive temperament, and ashamed; and described the "high-functioning" subtype of narcissist as a person less functionally impaired in the areas of life where narcissists with a severe expression of NPD usually have difficulties in functioning as a normally-socialized person.

In the study Disorders of Personality: DSM-IV-TM and Beyond (1996), Theodore Millon suggested five subtypes of narcissist; however, there are few, pure subtypes of narcissist. Moreover, Millon's five subtypes of narcissist are not recognized in either the Diagnostic or Statistical Manual of Mental Disorders or in the International Statistical Classification of Diseases and Related Health Problems.

·         Unprincipled narcissist:  Deficient conscience; unscrupulous, amoral, disloyal, fraudulent, deceptive, arrogant, exploitive; a con artist and charlatan; dominating, contemptuous, vindictive.

·         Amorous narcissist:  Sexually seductive, enticing, beguiling, tantalizing; glib and clever; disinclined to real intimacy; indulges hedonistic desires; bewitches and inveigles others; pathological lying and swindling. Tends to have many affairs, often with exotic partners.

·         Compensatory narcissist:  Seeks to counteract or cancel out deep feelings of inferiority and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, noteworthy; self-worth results from self-enhancement.

·         Elitist narcissist:  Feels privileged and empowered by virtue of special childhood status and pseudo-achievements; entitled façade bears little relation to reality; seeks favored and good life; is upwardly mobile; cultivates special status and advantages by association.

·         Normal narcissist:  Least severe and most interpersonally concerned and empathetic, still entitled and deficient in reciprocity; bold in environments, self-confident, competitive, seeks high targets, feels unique; talent in leadership positions; expecting of recognition from others.