Understanding Narcissistic Personality Disorder: The Concept of Narcissism | DSM-5 Criteria | ICD-11 Conceptualisation
Time to read: 6 minutes The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met according to DSM -5 :
A. Significant impairments in personality functioning manifest by:
- Impairments in self-functioning (a or b):
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- a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.
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- b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional or too low based on a sense of entitlement; often unaware of own motivations.
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2. Impairments in interpersonal functioning (a or b):
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- a. Empathy: Impaired ability to recognise or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
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- b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others‟ experiences and predominance of a need for personal gain
B. Pathological personality traits in the following domain:
- Antagonism is characterised by the following:
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- a. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.
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- b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
ICD-11 DIAGNOSTIC CRITERIA FOR BORDERLINE PATTERN OF PERSONALITY DISORDER OR PERSONALITY DIFFICULTY
The ICD-11 has 3 levels of description of personality disorders (PDs).
- Does the person have a personality disorder that fulfils the definition criteria?
- What is the level of severity?
- Are there trait domain specifiers? i.e. domains that describe the characteristics of the individual’s personality that are most prominent and contribute to personality disturbance.
The ICD-11 focuses on global and shared features that apply to all PDs.
ICD-11 definition of Personality disorder:
Personality Disorder is a marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption. The central manifestations of Personality Disorder are impairments in functioning of aspects of the self (e.g., identity, self-worth, capacity for self-direction) and/or problems in interpersonal functioning (e.g., developing and maintaining close and mutually satisfying relationships, understanding others’ perspectives, managing conflict in relationships). Impairments in self-functioning and/or interpersonal functioning are manifested in maladaptive (e.g., inflexible or poorly regulated) patterns of cognition, emotional experience, emotional expression, and behaviour.
Level of Severity:
Once the diagnosis of a Personality Disorder has been established, it should be described in terms of its level of severity:
- Mild Personality Disorder
- Moderate Personality Disorder
- Severe Personality Disorder
According to ICD-11, personality Disorder and personality Difficulty can be further described using five trait domain specifiers.
These trait domains describe the characteristics of the individual’s personality that are most prominent and that contribute to personality disturbance. As many as necessary to describe personality functioning should be applied.
Trait domain specifiers that may be recorded include the following: [ICD-11]
- Negative Affectivity
- Detachment
- Dissociality
- Disinhibition
- Anankastia
How can narcissistic personality disorder be conceptualised within the ICD-11? : [Bach et al., 2022]
Individuals with Narcissistic Personality Disorder (NPD) can have mild to severe symptoms.
The trait domain of Dissociality characterises narcissistic features with an emphasis on self-centeredness. This may include:
- A sense of exploitativeness towards others.
- The belief that they deserve whatever they want, and it should be obvious to others.
- The expectation of admiration from others and engaging in attention-seeking behaviours.
- Becoming angry or denigrating others when they don’t receive the expected admiration and attention.
- The belief that their accomplishments are outstanding and have many admirable qualities.
- Strong belief in their potential for greatness and expect others to admire them.
Other aspects include: [Bach et al., 2022]
- They have a fluctuating self-view, alternating between overly positive and negative.
- Narcissistic individuals may struggle to recover from damage to their self-image.
- They often exhibit poor emotion regulation and have difficulty developing close relationships.
- One-sided conflicts and dominance may characterise their relationships.
- Some narcissistic individuals may struggle to maintain regular work conditions or collaboration.
- Narcissistic individuals may also exhibit traits of perfectionism, vanity, and negative affectivity.
- The combination of dissociality, anankastia, and negative affectivity may indicate distinct features of narcissism, including perfectionistic overcompensation and rule-bound narcissistic dominance.
- Negative affectivity may include vulnerability, depression, anger, hostility, and shame features suggestive of vulnerable manifestations of narcissism.
- The combination of Dissociality and Negative Affectivity traits may indicate vulnerable narcissism in individuals who ruminate over perceived slights, overreact to criticism, and have low frustration tolerance. Their low self-esteem may lead to envy of others’ success and be driven by past failures and procrastination experiences.
- Different scales can capture various facets of narcissism, such as grandiosity, need for admiration, vanity, arrogance, selfishness, reactive anger, shame, self-centeredness, lack of empathy, and entitled superiority.
CONCEPT OF NARCISSISM
Narcissism is a psychological concept characterised by self-adoration and a disregard for the needs of others.
It has been a subject of concern for humans for a long time, and its origins can be traced back to Ovid’s myth of Narcissus in Metamorphoses (8 AD). In this myth, a Greek youth falls in love with his reflection and, unable to unite with his beloved image, wastes away and dies.
The term “narcissism” was initially coined by Ellis (1898) to describe auto-eroticism, a sexual perversion where an individual becomes sexually fixated on themselves.
Despite evolving usage, the term has consistently implied a positive and self-centred sexual attraction towards oneself.
The most widely accepted definition of narcissism is Hartmann’s (1950) description of it as “the libidinal investment of the self,” which closely aligns with Freud’s original formulation in his paper “On Narcissism: An Introduction” (1914) within his theory of libido.
Freud’s theory posited that individuals possess a fixed amount of libido, a life energy or sexual drive. According to Freud, when this libido is directed towards other people, it is known as object love. However, when it is directed towards oneself, it manifests as narcissism. This distinction forms a fundamental aspect of Freud’s understanding of narcissism and its relationship to object love.
Kernberg’s concept: [Russell, 1985]
- Pathological narcissism involves a pathological self-structure, i.e. the grandiose self as a defence against rage and envy.
- Normal immature narcissism is not the same as pathological narcissism.
- NPD is a subtype of borderline personality disorder
Kohut on pathological narcissism: [Russell, 1985]
- Pathological narcissism involves a fixation at an early stage of narcissistic development.
- Normal immature narcissism is the same as pathological narcissism.
- A clear distinction between NPD and borderline personality disorder
Kohut and Kernberg, however, agree that pathological narcissism involves a defective self and is influenced by disrupted attachment experiences.
They emphasise the significance of a “good enough” mother-child symbiosis in healthy narcissism, with NPD patients often lacking this nurturing bond.
Kernberg (1970, p. 59) maintains that narcissistic personalities often experienced their parents as callous and indifferent: ‘there is consistently a parental figure, usually the mother, who functions well on the surface. . . but with a degree of. . . nonverbalised spiteful aggression’. [Russell, 1985]
Shedler: [Feinstein et al, 2022]
Individuals with narcissistic personality are grandiose and entitled, dismissive and critical of others, and often show underlying signs of vulnera- bility beneath a grandiose façade.
Defence Mechanisms in Narcissism: [Russell, 1985], [Millon et al., 2012]
- Idealisation
- Devaluation / Denigration
- Unconscious repression
- Conscious denial
- Omnipotence
- Distortion (including exaggeration and minimisation), rationalisation and lies
- Psychological projection (blaming somebody else)
- Enlisting the help of one or more of their codependent friends who will support their distorted view.
MALIGNANT NARCISSISM
Malignant narcissism is a combination of narcissistic and antisocial-psychopathic traits. It involves narcissistic grandiosity paired with sadistic aggression, where demeaning or defeating others is necessary for the narcissist to feel important. [Feinstein et al, 2022]
This syndrome lacks an internalised moral system, leading to the exploitation and harm of others without remorse.
Malignant narcissists externalise blame and refuse to take responsibility for the consequences of their actions.
The convergence of psychopathic deception, exploitation, sadistic aggression, and externalisation with narcissistic grandiosity and self-importance can result in destructive behaviours.
References
American Psychiatric Association, & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA.
