Diagnosing NPD – what the manuals say

How does someone get a diagnosis of narcissistic personality disorder? Well there are two main sources of diagnostic criteria for mental health conditions. One is the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association, the other is the ICD-10 Classification of Mental and Behavioural Disorders published by the World Health Authority. If the person meets the criteria for diagnosis as listed in these academic publications then their clinician (a GP, psychiatrist or psychoanalyst) would be able to diagnose narcissistic personality disorder. Only its not as simple as that.

First off the DSM has changed the criteria for diagnosing personality disorders. The previous edition DSM IV had one version and the present version DSM V has a rather different version. The ICD-10 doesn’t list Narcissistic Personality Disorder at all in the main body of the classification, it could be diagnosed as an other personality disorder not fitting the listed disorders. They include a comment on NPD in the appendix where the DSM IV criteria and listed and it is suggested this is a topic for further discussion and research.

So why all the contradiction and disagreement? The DSM IV criteria have been criticised from within the psychiatric medical community on several points.

Firstly the emphasis in the diagnostic criteria in DSM IV is placed on  the way NPD appears to outside observers in the actions and behaviours of the PD person. Not a lot of emphasis is put on the internal state of mind and thought processes occurring in the PD person which then lead to the behaviours. The result of this is twofold. The clinician has little to go on when trying identify NPD in a therapeutic situation. Imagine a person has all sorts of problems with their relationships and gets depressed, sees a doctor and starts talking about their feelings and thoughts. The DMS IV describes behaviours in a social-interpersonal setting which the clinician never sees. The clinician needs more information about the internal landscape of someone with NPD to identify it in a person in therapy.

The other problem is that the behaviours of someone with NPD overlap with behaviours shown by other personality disorders. This blurring of the boundaries of personality disorders is unhelpful if you believe (as I think many psychiatrists do) that each disorder is caused by a particular and specific developmental disruption in the person’s early life. The nature of the damage done and the age it occurred at will uniquely determine the manifestation of the disorder. Well I’m not sure I would be confident in supporting that discrete definition in its entirity but that seems to be the underlying assumption in wanting less overlap between the disorders.

If the definition of the disorder is heavily behaviourally based there will always be a tendency for cross-diagnosis between disorders as two people can behave in a similar way for entirely different reasons. Ideally one needs to identify the key features of the disorder as they appear externally to others and internally as the person experiences it themselves. The marked thing about NPD is that the external presentation of behaviours almost completely contradicts the internal experience of the sufferer. They act extremely self assured and superior, they feel utterly ashamed and inferior. The external behaviour is enacted as a way of suppressing the internal feelings which the NPD sufferer has, in the main, stuffed into their subconscious.

This criticism of the DSM IV criteria and general debate on the subject in the clinical literature means there has been no agreement between DSM and ICD-10. There is no argument that such a set of behaviours for the surmised reasons exists. NPD is seen in many clinical settings. ICD-10 wants a clear set of symptoms before it will include NPD as a specific named personality disorder, DSM updates itself periodically to try and keep abreast of developments. The WHO manual is more conservative, the American manual is criticised for medicalising all manner of behaviours and being in hock to large pharmaceutical companies (who for a price will sell you a drug to treat the disorders in the DSM).

Below is a straight copy and paste from the relevant tomes.

DSM IV Criteria for diagnosing a personality disorder

A. An enduring pattern of inner experience and behavior the deviates  markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people and events)
2. Affectivity (i.e., the range, intensity, liability, and appropriateness of emotional response)
3. Interpersonal functioning
4. Impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma).

DSM IV criteria for NPD

A. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized 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 highstatus people (or institutions).

4. Requires excessive admiration.

5. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable 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.

DSM V criteria for diagnosing a personality disorder

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:

A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.

B. One or more pathological personality trait domains or trait facets.

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 sociocultural 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).

DSM V criteria for NPD

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:

A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):

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.

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.

AND

2. Impairments in interpersonal functioning (a or b):

a. Empathy: Impaired ability to recognize 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.

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:
1. Antagonism, characterized by:
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.

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-10 Criteria for diagnosing a personality disorder

Conditions not directly attributable to gross brain damage or disease, or to
another psychiatric disorder, meeting the following criteria:
(a)markedly disharmonious attitudes and behaviour, involving usually several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
(b)the abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;
(c)the abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
(d)the above manifestations always appear during childhood or adolescence and continue into adulthood;
(e)the disorder leads to considerable personal distress but this may only become apparent late in its course;
(f)the disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

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Filed under Describing narcissism, diagnosing NPD, Examples of narcissistic behaviour, Understanding narcissism

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