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NarcissisticPersonalityDisorder(NPD):DSMIVDiagnosticCriteria

Introduction|Whatisapersonalitydisorder?|NarcissisticPersonalityDisorder
Howtorecognizeanarcissist|Traitsdiscussed|"NowWeAreSix"|"It'saGoodLife"
What'snormal?|Furtherreading|Attachment|Narcissusinart|Aftermath|Beyond|Music

Whatisapersonalitydisorder?
[fromDiagnosticandStatisticalManualofMentalDisorders,4thedition,1994,commonly
referredtoasDSMIV,oftheAmericanPsychiatricAssociation.Europeancountriesuse
thediagnosticcriteriaoftheWorldHealthOrganization.]

Anenduringpatternofinnerexperienceandbehaviorthatdeviates
markedlyfromtheexpectationoftheindividual'sculture,ispervasive
andinflexible,hasanonsetinadolescenceorearlyadulthood,isstable
overtime,andleadstodistressorimpairment.
Apersonalitydisorderisapatternofdeviantorabnormalbehaviorthatthe
persondoesn'tchangeeventhoughitcausesemotionalupsetsandtroublewith
otherpeopleatworkandinpersonalrelationships.Itisnotlimitedtoepisodesof
mentalillness,anditisnotcausedbydrugoralcoholuse,headinjury,orillness.
Thereareaboutadozendifferentbehaviorpatternsclassifiedaspersonality
disordersbyDSMIV.Allthepersonalitydisordersshowupasdeviationsfrom
normalinoneormoreofthefollowing:
(1)cognitioni.e.,perception,thinking,andinterpretationofoneself,other
people,andevents
(2)affectivityi.e.,emotionalresponses(range,intensity,lability,
appropriateness)
(3)interpersonalfunctions
(4)impulsivity.

NarcissisticPersonalityDisorder
Whilegrandiosityisthediagnostichallmarkofpathologicalnarcissism,there
isresearchevidencethatpathologicalnarcissismoccursintwoforms,(a)a
grandiosestateofmindinyoungadultsthatcanbecorrectedbylifeexperiences,
and(b)thestabledisorderdescribedinDSMIV,whichisdefinedlessby
grandiositythanbyseverelydisturbedinterpersonalrelations.
Thepreferredtheoryseemstobethatnarcissismiscausedbyveryearly
affectivedeprivation,yettheclinicalmaterialtendstodescribenarcissists
asunwillingratherthanunable,thustreatingnarcissisticbehaviorsasvolitional
thatis,narcissismistermedapersonalitydisorder,butittendstobediscussed
asacharacterdisorder.Thisdistinctionisimportanttoprognosisand
treatmentpossibilities.IfNPDiscausedbyinfantiledamageandconsequent
developmentalshortcircuits,itprobablyrepresentsanirremediablecondition.
Ontheotherhand,ifnarcissismisabehaviorpatternthat'slearned,thenthereis
somehope,howevertenuous,thatit'sabehaviorpatternthatcanbeunlearned.
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TheclinicalliteratureonNPDishighlytheoretical,abstract,andgeneral,with
sparsecasematerial,suggestingthatclinicalwritershavelittleexperiencewith
narcissismintheflesh.Thereareseveralreasonsforthistobeso:
TheincidenceofNPDisestimatedat1%inthegeneralpopulation,thoughI
haven'tbeenabletodiscoverthebasisofthisestimate.
Narcissistsrarelyentertreatmentand,onceintreatment,progressveryslowly.
We'retalkingabouttwoormoreyearsoffrequentsessionsbeforethenarcissist
canacknowledgeeventhatthetherapistissometimeshelpful.It'sdifficultto
keepnarcissistsintreatmentlongenoughforimprovementtobemadeand
fewpeople,narcissistsornot,havethemotivationorthemoneytopursue
treatmentthatproducessolittlesolate.
Becauseoftheinfluenceofthirdpartypayers(insurancecompanies),there
hasbeenastrongtrendtowardsshorttermtherapythatconcentrateson
amelioratingacutetroubles,suchasdepression,ratherthandelvinginto
underlyingchronicproblems.Narcissistsareveryreluctanttoopenupandtrust,
soit'spossiblethattheirNPDisnotevenrecognizedbytherapistsinshortterm
treatment.Purelyanecdotalevidencefromcorrespondentsandfromobservations
ofpeopleIknowindicatesthatselectiveserotoninreuptakeinhibitors,suchas
Prozac,aggravatenarcissists'grandiosityandlackofsocialinhibition.Ithasalso
beensuggestedthatselfhelpliteratureaboutbolsteringselfesteemandgetting
whatyouwantoutoflifeorthatencouragesthefeelingofvictimizationhas
aggravatingeffectsonNPDthinkingandbehavior.
Mostclinicalwritersseemunawarethatnarcissists'selfreportsareunreliable.
Thisistroubling,consideringthatlyingisthemostcommoncomplaintabout
narcissistsandthat,inmanyinstances,defectsofempathyleadnarcissiststo
wildlyinaccuratemisinterpretationsofotherpeople'sspeechandactions,sothat
theymaybelievethattheyarelikedandrespecteddespiteahistoryofcallous
andexploitativepersonalinteractions.
[fromDiagnosticandStatisticalManualofMentalDisorders,4thedition,1994,commonly
referredtoasDSMIV,oftheAmericanPsychiatricAssociation.Europeancountriesuse
thediagnosticcriteriaoftheWorldHealthOrganization.]

Apervasivepatternofgrandiosity(infantasyorbehavior),needfor
admiration,andlackofempathy.[jma:NPDfirstappearedinDSMIIIin
1980beforethattimetherehadbeennoformaldiagnosticdescription.
Additionally,thereisconsiderableoverlapbetweenpersonalitydisordersand
clinicianstendtodiagnosemixesoftwoormore.Grandiosityisaspecial
case,butlackofempathyandexploitativeinterpersonalrelationsarenot
uniquetoNPD,noristheneedtobeseenasspecialorunique.The
differentialdiagnosisofNPDismadeontheabsenceofspecificgross
behaviors.BorderlinePersonalityDisorderhasseveralconspicuous
similaritiestoNPD,butBPDischaracterizedbyselfinjuryandthreatenedor
attemptedsuicide,whereasnarcissistsarerarelyselfharminginthisway.
BPDmayincludepsychoticbreaks,andtheseareuncharacteristicofNPDbut
notunknown.TheneedforconstantattentionisalsofoundinHistrionic
PersonalityDisorder,butHPDandBPDarebothstronglyorientedtowards
relationships,whereasNPDischaracterizedbyaloofnessandavoidanceof
intimacy.GrandiosityisuniquetoNPDamongpersonalitydisorders,butitis
foundinotherpsychiatricillnesses.Psychopathsdisplaypathological
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narcissism,includinggrandiosity,butpsychopathyisdifferentiatedfrom
NPDbypsychopaths'willingnesstousephysicalviolencetogetwhatthey
want,whereasnarcissistsrarelycommitcrimesthenarcissistsI'veknown
personallyare,infact,aversetophysicalcontactwithothers,thoughtheywill
occasionallystrikeoutinanimpulseofrage.Ithasbeenfoundthatcourt
orderedpsychotherapyforpsychopathsactuallyincreasestheirrecidivism
rateapparentlytreatmentteachespsychopathsnewwaystoexploitother
people.Bipolarillnessalsocontainsstrongelementsofgrandiosity.Seemore
ongrandiosityandempathyanditslackbelow.]Thedisorderbeginsby
earlyadulthoodandisindicatedbyatleastfiveofthefollowing:
Translation:NarcissisticPersonalityDisorder(NPD)isapatternofself
centeredoregotisticalbehaviorthatshowsupinthinkingandbehaviorinalotof
differentsituationsandactivities.PeoplewithNPDwon't(orcan't)changetheir
behaviorevenwhenitcausesproblemsatworkorwhenotherpeoplecomplain
aboutthewaytheyact,orwhentheirbehaviorcausesalotofemotionaldistress
toothers(orthemselves?noneofmynarcissistseveradmittobeingdistressed
bytheirownbehaviortheyalwaysblameotherpeopleforanyproblems).This
patternofselfcenteredoregotisticalbehaviorisnotcausedbycurrentdrugor
alcoholuse,headinjury,acutepsychoticepisodes,oranyotherillness,buthas
beengoingonsteadilyatleastsinceadolescenceorearlyadulthood.
NPDinterfereswithpeople'sfunctioningintheiroccupationsandintheir
relationships:
Mildimpairmentwhenselfcenteredoregotisticalbehaviorresultsin
occasionalminorproblems,butthepersonisgenerallydoingprettywell.
Moderateimpairmentwhenselfcenteredoregotisticalbehaviorresultsin:(a)
missingdaysfromwork,householdduties,orschool,(b)significant
performanceproblemsasawageearner,homemaker,orstudent,(c)frequently
avoidingoralienatingfriends,(d)significantriskofharmingselforothers
(frequentsuicidalpreoccupationoftenneglectingfamily,orfrequentlyabusing
othersorcommittingcriminalacts).
Severeimpairmentwhenselfcenteredoregotisticalbehaviorresultsin:(a)
stayinginbedallday,(b)totallyalienatingallfriendsandfamily,(c)severerisk
ofharmingselforothers(failingtomaintainpersonalhygienepersistentdanger
ofsuicide,abuse,orcrime).
1.Anexaggeratedsenseofselfimportance(e.g.,exaggerates
achievementsandtalents,expectstoberecognizedassuperiorwithout
commensurateachievements)
Translation:Grandiosityisthehallmarkofnarcissism.Sowhatisgrandiose?
Thesimplesteverydaywaythatnarcissistsshowtheirexaggeratedsenseofself
importanceisbytalkingaboutfamily,work,lifeingeneralasifthereisnobody
elseinthepicture.Whatevertheymaybedoing,intheirownview,theyarethe
star,andtheygivetheimpressionthattheyarebearingheroicresponsibilityfor
theirfamilyordepartmentorcompany,thattheyhavetotakecareofeverything
becausetheirspousesorcoworkersareundependable,uncooperative,or
otherwiseunfit.Theyignoreordenigratetheabilitiesandcontributionsofothers
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andcomplainthattheyreceivenohelpatalltheymayinspireyoursympathyor
admirationfortheirstoicisminthefaceofhardshiporunstintingselfsacrifice
forthegoodof(undeserving)others.Butthiseverydaygrandiosityisanaspect
ofnarcissismthatyoumaynevercatchontounlessyouvisitthenarcissist's
homeorworkplaceandseeforyourselfthatothersareinvolvedandarepulling
theirshareoftheloadand,moreoftenthannot,arealsopullingthenarcissist's
shareaswell.Anexampleistheolderwomanwhotoldmewithasighthatshe
knewshehadn'tbeenaperfectmotherbutshejustneverhadanyhelpatall
andshesaidthisdespiteknowingthatIknewthatshehadwornoutand
discardedtwodevotedhusbandsandhadlivedinherparents'pocket(and
pocketbook)aslongastheylived,quicklyblowinghersubstantialinheritanceon
flakybusinessschemes.Anotherexampleisclaimingunusualbenefitsor
spectacularresultsfromordinaryeffortandinvestment,givingtheimpression
thatsomehowthenarcissist'stimeandmoneyareworthmorethanother
people's.[Hereisanarticleaboutrecognizingandcopingwithnarcissisminthe
workplaceitisratherheavyonmanagementjargonandpsychobabble,but
worthreading."TheImpactofNarcissismonLeadershipandSustainability"by
BruceGregory,Ph.D."Whenthenarcissisticdefenseisoperatinginan
interpersonalorgroupsetting,thegrandiosepartdoesnotshowitsfacein
public.Inpublicitpresentsafrontofpatience,congeniality,andconfident
reasonableness."]
Inpopularusage,thetermsnarcissism,narcissist,andnarcissisticdenote
absurdvanityandareappliedtopeoplewhoseambitionsandaspirationsare
muchgranderthantheirevidenttalents.Sometimesthesetermsareappliedto
peoplewhoaresimplyfullofthemselvesevenwhentheirrealachievements
arespectacular.Outstandingperformersarenotalwaysmodest,buttheyaren't
grandioseiftheirselfassessmentsarerealistice.g.,MuhammadAli,then
CassiusClay,wasnotoriousforboasting"Iamthegreatest!"andalsopointing
outthathewastheprettiest,buthewasthegreatestandtheprettiestfora
numberofyears,sohisselfassessmentsweren'tgrandiose.Somenarcissistsare
flamboyantlyboastfulandselfaggrandizing,butmanyareinconspicuousin
public,savingtheirconceitandautocraticopinionsfortheirnearestanddearest.
Commonconspicuousgrandiosebehaviorsincludeexpectingspecialtreatment
oradmirationonthebasisofclaiming(a)toknowimportant,powerfulor
famouspeopleor(b)tobeextraordinarilyintelligentortalented.Asareallife
example,Iusedtohaveaneighborwhotoldhiswifethathewastheyoungest
personsinceSirIsaacNewtontotakeadoctorateatOxford.Theneighborgave
noevidenceofaworldclasseducation,soIlookedupNewtonandfoundout
thatNewtonhadcompletedhisbaccalaureateattheageoftwentytwo(likemost
people)andspenthisentireacademiccareeratCambridge.Thegrandioseclaims
ofnarcissistsaresuperficiallyplausiblefabrications,readilypuncturedbyalittle
criticalconsideration.Thetestisperformance:dotheydeliverthegoods?
(There'salsothespecialsituationofageniuswho'salsostronglynarcissistic,as
perhapsFrankLloydWright.Justremindyourselfthattheoddsarethatyou'll
meetatleast1000narcissistsforeverygeniusyoucomeacross.)[More
ongrandiosity.]
2.Preoccupationwithfantasiesofunlimitedsuccess,power,brilliance,
beauty,orideallove
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Translation:Narcissistscultivatesolipsisticor"autistic"fantasies,whichisto
saythattheyliveintheirownlittleworlds(andreactwithaffrontwhenreality
darestointrude).
3.Believesheis"special"andcanonlybeunderstoodby,orshould
associatewith,otherspecialorhighstatuspeople(orinstitutions)
Translation:Narcissiststhinkthateveryonewhoisnotspecialandsuperioris
worthless.Bydefinition,normal,ordinary,andaveragearen'tspecialand
superior,andso,tonarcissists,theyareworthless.
4.Requiresexcessiveadmiration
Translation:Excessiveintwoways:theywantpraise,compliments,deference,
andexpressionsofenvyallthetime,andtheywanttobetoldthateverything
theydoisbetterthanwhatotherscando.Sincerityisnotanissuehereallthat
matterarefrequencyandvolume.
5.Hasasenseofentitlement
Translation:Theyexpectautomaticcompliancewiththeirwishesorespecially
favorabletreatment,suchasthinkingthattheyshouldalwaysbeabletogofirst
andthatotherpeopleshouldstopwhateverthey'redoingtodowhatthe
narcissistswant,andmayreactwithhurtorragewhentheseexpectationsare
frustrated.
6.Selfishlytakesadvantageofotherstoachievehisownends

Translation:Narcissistsuseotherpeopletogetwhattheywantwithoutcaring
aboutthecosttotheotherpeople.
7.Lacksempathy
Translation:Theyareunwillingtorecognizeorsympathizewithotherpeople's
feelingsandneeds.They"tuneout"whenotherpeoplewanttotalkabouttheir
ownproblems.
Inclinicalterms,empathyistheabilitytorecognizeandinterpretother
people'semotions.Lackofempathymaytaketwodifferentdirections:(a)
accurateinterpretationofothers'emotionswithnoconcernforothers'distress,
whichischaracteristicofpsychopathsand(b)theinabilitytorecognizeand
accuratelyinterpretotherpeople'semotions,whichistheNPDstyle.Thissecond
formofdefectiveempathymay(rarely)gosofarasalexithymia,ornowordsfor
emotions,andisfoundwithpsychosomaticillnesses,i.e.,medicalconditionsin
whichemotionisexperiencedsomaticallyratherthanpsychically.Peoplewith
personalitydisordersdon'thavethenormalbodyegoidentificationandregard
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theirbodiesonlyinstrumentally,i.e.,astoolstousetogetwhattheywant,or,in
badstates,astorturechambersthatinflictonthemmeaninglesssuffering.Self
describednarcissistswho'vewrittentomesaythattheyareawarethattheir
feelingsaredifferentfromotherpeople's,mostlythattheyfeelless,bothin
strengthandvariety(andwhichthenarcissistsinterpretasevidenceoftheirown
superiority)somenarcissistsreport"numbness"andtheinabilitytoperceive
meaninginotherpeople'semotions.
8.Isoftenenviousofothersorbelievesthatothersareenviousofhim
Translation:Notranslationneeded.
9.Showsarrogant,haughty,patronizing,orcontemptuousbehaviorsor
attitudes

Translation:Theytreatotherpeoplelikedirt.
[SomedescriptionsandexplanationsonthispagearebasedonmaterialfromWhatisa
personalitydisorder?byPaulJ.Hannig,Ph.D.,TheOnlineJournalofPsychiatry,Narcissistic
PersonalityDisorder,and(defunct)InternetMentalHealthquestionnairefordiagnosisof
NarcissisticPersonalityDisorder.Forafirsthandaccountofwhatit'sliketohaveNPD,
see"MalignantSelfLoveNarcissismRevisited"byShmuel(Sam)Vaknin,Ph.D.]

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