1. Diagnostic and Statistical Manual (DSM-V) Narcissistic Personality Disorder
2. Typologies of Narcissism: Covert and Overt
3. The Dark Triad: relation to narcissism
4. Implications of Narcissism on culture and society
5. Issues with treatment of Narcissistic Personality Disorder
Narcissistic terminology derives from Greek mythology, and the story of Narcissus, who fell in love with his own frozen reflection in the water whilst growing old pondering the beauty of the stranger - the stranger being his own reflection, of which he can never obtain intimacy with, and shunning anyone else from becoming intimately or personally involved with him out of his own proudness1. This self-absorption, pursuit of perfectionism and problems with interpersonal relationships is the defining feature of what became known as Narcissistic Personality Disorder, a form of malignant narcissism (American Psychiatric Association, 2013) with life-long maladaptive traits2 - the criteria of Personality Disorders (PD). Narcissism is a unique predictor of several behavioural outcomes such as criminal behaviour, interpersonal problems, anger, workplace incivility, aggression, and difficulties in psychotherapy3 4. Narcissistic Personality Disorder has received the least empirical attention of the 10 existing PDs5. NPD first entered the DSM-III in 1980, and has undergone many changes since its creation based on psychoanalytical literature6 and largely anecdotal evidence. The Diagnostic and Statistical Manual V (DSM-V) contains nine such criteria that are representative of the pervasive, and maladaptive nature of the Cluster B Personality Disorder diagnosis:
1. Diagnostic Criteria (APA, 2013):
1. Has a grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognised as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e. unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e. takes advantage of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
However a narcissistic personality can also be referred to as healthy narcissism7 8. This refers to having a healthy sense of one’s self-worth; accurate representation of one’s own achievements; and does not cause interpersonal difficulties with primitive psychological defence mechanisms displayed such as minimization, projection and intellectualization.
This discrepancy of definitions has led to various typologies that have been established by current researchers such as pathological narcissism; malignant narcissism; covert narcissism and overt narcissism9. Previously the DSM-IV-TR (APA, 2000) focused on the grandiosity and display of superiority in the diagnostic criteria, however, research indicated that narcissists despite an external display of behavioural symptoms also have an internal range of behavioural characteristics which largely remain hidden in community settings due to the outward persona narcissism displays. For instance, the narcissist, in accordance with narcissism as a defence mechanism (Freud, 1924) projects onto the world a ‘false self’10 or ‘false image’11, which displays the perfect ideal of what the narcissist wants the world, and society to see him/her as; perfectionism is a core trait that they share with other PDs12. However this image can be fragile, and unstable, (vulnerable narcissism) depending on others to condition and bolster this sense of specialness/uniqueness which can often be somatic or intellectual in nature. If the narcissist does not receive this special treatment from others, they can become very distressed; depressed; angry; and dependent on narcissism based on fear and intimidation for their balancing act of self-worth13. The DSM-V (APA, 2013) addresses this previous limitation, by including in their ‘ Associated Features Supporting Diagnosis ’ (APA, 2013, p. 671) that vulnerability in their self-esteem makes them very sensitive to outside commentaries and perceived motivations. However research still indicates that narcissism as a diagnosis has limited clinical utility, with high rates of comorbidity with other Cluster B Personality Disorders, particularly Borderline Personality Disorder and Anti-Social Personality Disorder (ASPD). The Work Group involved in the formulation of the DSM-V proposed scrapping the diagnosis of Narcissistic Personality Disorder from the new DSM-V (2013) due to low clinical utility and high comorbidity with other Cluster B disorders of greater clinical utility. However, researchers across the field of narcissism campaigned and protested against the APA proposal which led to the diagnosis entering the fifth edition – however, the emphasis from the APA has been to research and gather empirical data on the clinical utility of Section III of the guide which provides a personality severity measure of specific personality disorders, using a hybrid dimensional-categorical alternative model as opposed to a categorical diagnosis.
2. Covert and Overt Narcissism:
Overt-Narcissism – described as Grandiosity-Exhibitionism consists of exhibitionism, an exaggerated sense of self-importance, grandiosity and desire for attention.14
Covert-Narcissism – described as Vulnerability-Sensitivity form of narcissism is characterised by hypersensitivity to criticism, a lack of self-confidence, being socially withdrawn, but similar to the overt form, an element of grandiosity. Covert at its core has an element of insecurity in their exhibitionism - research has confirmed the existence of these two separate typologies15 – coverts showing far more distress and internal traits of frustration and depression. However the Overt type is likely to deny any negative psycho-social problems in order to keep the false image of themselves apparent.16
Psychoanalytic perspectives have identified pathological narcissism as a defensive grandiosity in compensation for underlying feelings of inferiority.17 This perspective perceives narcissism as an error in the developmental phases of the child, and as such they are stuck in a childlike developmental stage. Therefore the theory is limited at accounting for positive narcissism and the success that can be gained by behavioural traits such as a lack of empathy in business and law professions.
Social Learning Theory – theorists have argued that narcissism may consist of genuine underlying beliefs of superiority – environment has nurtured this sense of specialness and uniqueness based on developmental factors such as high parent expectations; parental praise and peer idealization.18 The limitation is that it fails to acknowledge internal conflicts of low self-esteem, repressed inferiority and depression traits.
3. Dark Triad: Narcissism links with criminality and forensic issues:
The Dark Triad was coined by Paulhus and Williams (2002) in their article on the social maladaptive link between different malevolent characters; thereby establishing a unitary construct to approaching criminal behaviour, and the traits likely to be present. Three categories were identified; Machiavellianism; Narcissism and Psychopathy. The narcissism reflecting the self-entitlement, egotism, and lack of empathy of criminals such as burglars and paedophiles. Narcissism within the construct of the Dark Triad is frequently measured with the Narcissistic Personality Inventory (NPI). The NPI (1988) is the main methodology of measurement used by researchers to investigate empirical narcissism. However it has been criticised heavily by researchers for its poor internal reliability of the sub-scales and reliance on a global score rather than measuring independent factors specifically19. The factorial structure has also been criticised. Furthermore it does not focus on the maladaptive traits of the disorder primarily, which means its measurements could be measuring other constructs (discriminant validity). Grandiose narcissism and Machiavellianism are frequently included in most conceptualizations of psychopathy and psychopathic personality. Proponents of the Dark Triad have argued that narcissism constitutes a facet of the construct of psychopathy, or may even be a lower level of psychopathy in terms of destructive functioning; akin to the divide proposed between primary psychopathy (scheming, manipulative) and secondary psychopathy (anti-social) variant with neurological differences with each typologies. Therefore narcissism is at the very least an important behavioural trait that enables criminality to potentially occur, serving as a predisposition trait that should be assessed for in clinical and forensic populations as a risk factor.
4. Implications of Narcissism on culture and society:
The notion of cultural narcissism became a topic of psychological and enquiry, and now mainstream debate after Christopher Lasch wrote The Culture of Narcissism (1978). Lasch identified a hedonistic society that had become obsessed with wealth, and where every interaction was geared towards gaining this resource. This has become far more mainstream with left discourse on capitalism, and the rise of modern day consumerism as a concern of societal functions such as the family unit20. The growth of online technologies has fuelled this debate further, and in turn made narcissism, and the concept of the narcissist a popular topic of debate within western terminology and literature. Cultural theorists have argued that the disorder of NPD is a cultural bound syndrome, rather than an isolated mental health problems of patients. Society has been proliferating narcissism, and akin to a disease, many of us are now exhibiting these traits because our society has become fundamentally narcissistic – our western obsession with celebrities and consumerism are cited as evidence of this concept.
5. Issues with treatment of Narcissistic Personality Disorder:
Due to the nature of the disorder there is a reliance on the patient to maintain his/hers sense of omnipotence and false image in the therapeutic relationship. Therefore a therapist, psychologist or other mental wellbeing practitioner may constitute a threat to the perceived status advantage of a narcissistic patient21. Hostility and narcissistic rage can occur, which leads to high dropout rates, and most importantly a significant lack of clinical participants for studies. In addition it has also been acknowledged that the narcissistic patient may devalue, undermine and critique the credentials of the practitioner when they’re in a therapeutic setting22. Experiences of paranoia and suspicion can arise, and projections of perceived superiority from the therapist can make the patient feel they’re being challenged or questioned. Furthermore the clinical setting can require the communication of distressing and embarrassing memories which the narcissistic patient may be keen to avoid, particular if there is background of peer or familial abuse(s)23. In a forensic setting caution should be maintained for any signs of a breakdown in the therapeutic relationship, avoid any attempts to confront the patient and instead use open ended discussion and allow the patient to use his/her autobiographical episodes as the premise for talking points24.
References (APA 6th Edition):
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2003). APA (2000). Diagnostic and statistical manual of mental disorders, 4.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Brookes, J. (2015). The effect of overt and covert narcissism on self-esteem and self-efficacy beyond self-esteem. Personality and Individual Differences, 85, 172-175.
Clarke, I. E., Karlov, L., & Neale, N. J. (2015). The many faces of narcissism: Narcissism factors and their predictive utility. Personality and Individual Differences, 81, 90-95.
Diamond, D., Yeomans, F., & Levy, K. N. (2011). Psychodynamic psychotherapy for narcissistic personality. The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings, and treatments, 421-433.
Dimaggio, G., & Attinà, G. (2012). Metacognitive interpersonal therapy for narcissistic personality disorder and associated perfectionism. Journal of clinical psychology, 68 (8), 922-934.
Foster, J. D., McCain, J. L., Hibberts, M. F., Brunell, A. B., & Johnson, R. B. (2015). The Grandiose Narcissism Scale: A global and facet-level measure of grandiose narcissism. Personality and individual differences, 73, 12-16.
Freud, S. (1924). A short account of psychoanalysis. Standard Edition, 19.
Horwitz, L. (2000). Narcissistic leadership in psychotherapy groups. International journal of group psychotherapy, 50 (2), 219-235.
Kernberg, O. (1975). Normal and pathological narcissism: Structural and clinical aspects. Borderline conditions and pathological narcissism, 315-342.
Kernberg, O. F. (2012). Review articles-Overview and critique of the classification of personality disorders proposed for DSM-V. Schweizer Archiv fur Neurologie und Psychiatrie, 163 (7), 234.
Kohut, H. (1972). Thoughts on narcissism and narcissistic rage. Psychoanalytic study of the child, 27 (1), 360-400.
Lasch, C. (1980). The culture of narcissism. Bulletin of the Menninger Clinic, 44 (5), 426. Retrieved from https://search.proquest.com/docview/1298150403?accountid=16461.
MacDonald, P. (2014). Narcissism in the modern world. Psychodynamic practice, 20 (2), 144-153.
Millon, T. (1981). Disorders of personality: DSM-III, axis II. John Wiley & Sons.
Pies, R. (2011). How to eliminate narcissism overnight: DSM-V and the death of narcissistic personality disorder. Innovations in clinical neuroscience, 8 (2), 23.
Pincus, A. L., Cain, N. M., & Wright, A. G. (2014). Narcissistic grandiosity and narcissistic vulnerability in psychotherapy. Personality Disorders: Theory, Research, and Treatment, 5 (4), 439-443.
Roepke, S., & Vater, A. (2014). Narcissistic personality disorder: an integrative review of recent empirical data and current definitions. Current psychiatry reports, 16 (5), 1-9.
Ronningstam, E. (2010). Narcissistic personality disorder: a current review. Current Psychiatry Reports, 12 (1), 68-75.
Stinson, F. S., Dawson, D. A., Goldstein, R. B., Chou, S. P., Huang, B., Smith, S. M., ... & Grant, B. F. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions. The Journal of clinical psychiatry, 69 (7), 1033.
Stoeber, J., Sherry, S. B., & Nealis, L. J. (2015). Multidimensional perfectionism and narcissism: Grandiose or vulnerable?. Personality and Individual Differences, 80, 85-90. Vaknin, S. (2001). Malignant self love: Narcissism revisited. Narcissus Publishing. Wink, P. (1991). Two faces of narcissism. Journal of personality and social psychology, 61 (4), 590.
1 MacDonald, 2014.
2 Pies, 2011.
3 Pincus, Cain & Wright, 2014.
4 Stoeber. Sherry and Nealis, 2015.
5 Stinson et al, 2008.
6 Roepke & Vater, 2014.
7 MacDonald, 2014.
8 Horwitz, 2000.
9 Kernberg, 2012.
10 Vaknin, 2001.
11 Kohut, 1972.
12 Ronningstam, 2010.
13 Kernberg, 1975.
14 Wink, 1991.
15 Clarke et al, 2015.
16 Brookes, 2015.
17 Kernberg, 1975.
18 Millon, 1981.
19 Foster et al, 2015.
20 MacDonald, 2014.
21 Yeomans, 2012.
22 Diamond et al, 2012.
23 Hinrichs, 2016.
24 Dimaggio & Attinà, 2012.