Narcissistic Personality Disorder: Facing DSM-V

Elsa Ronningstam, PhD

sychoanalytic theories and clini- cal case studies of patients with Pnarcissistic character pathology were most infl uential in outlining the conceptualization and description of the narcissistic personality disorder (NPD) when it was fi rst included as a diagnostic category in the Diagnostic and Statistic Manual of Mental Disorders, third edi- tion, (DSM-III) in 1980. This was elo- quently summarized by Salman Akhtar.1 Infl uences from other disciplines, (ie, psychiatric and psychosocial research on epidemiology and prototypical features), as well as academic social psychological inventory and laboratory studies of hu- man behavior, have contributed additional perspectives on pathological narcissism and NPD. More recently, cognitive neu- ropsychology and studies of infant and child development have also added valu- able information to our understanding of the origins of pathological narcissism and specifi c areas of narcissistic personality functioning. Three recent reviews2-4 have

Elsa Ronningstam, PhD, is Associate Clinical Professor, Harvard Medical School, and Psychol- ogist, McLean Hospital. Address correspondence to: Elsa Ron- ningstam, PhD, McLean Hospital, 115 Mill Street, Belmont MA 02478; or e-mail ron- [email protected]. Dr. Ronningstam has disclosed no relevant fi nancial relationships. © Medusa Lemieux / Pennsylvania College of Art & Design

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33903Ronningstam.indd903Ronningstam.indd 111111 33/11/2009/11/2009 3:27:473:27:47 PPMM men and 4.8% for women) in the general TABLE 1. population, with considerable psycho- Prevalence of NPD social disability, especially among men, and co-occurring mood disorders (de- General population 0%-5.3%86-90 pression, bipolar I disorder), anxiety Wave 2, NESARC lifetime prevalence 4.8%-7.7%13 Clinical population 1.3%-17%53,91-94 disorder, personality disorders, and sub- Forensic population 6%95 stance use disorder. Outpatient private practice 8.5%-20%67,96,97 On the other hand, the NPD diagno- Military setting (NPD and NP traits) 20%98, 99 sis has more often been reported in out- Medical school, fi rst-year students 17%100 patient private practice and small clinics as compared with the general population and larger psychiatric settings. NPD has summarized available knowledge and toms that to various degrees infl uence also been diagnosed in non-psychiatric suggested new avenues toward improve- and limit interpersonal and/or vocation- professional settings such as the mili- ment in diagnosis and clinical conceptu- al functioning, or as context-determined tary and medical school, indicating that alization of NPD. narcissistic reactions.5,6 Independently NPD does not necessarily cause nor is it Clinical accounts of the narcissistic of level of severity, pathological narcis- necessarily accompanied by impairment personality indicate a range of charac- sism can either show as overt, striking in ability to work, or in social or daily teristics and behaviors among these pa- and obtrusive symptoms and function- functioning. In other words, people with tients. Some match the typical expecta- ing, or it can be internally concealed and NPD, contrary to most other personality tion of a narcissistic personality (ie, being unnoticeable.1,7 Narcissism can also take disorders, include both those who are boastful, assertive, and arrogant). Others malignant forms and co-occur with anti- high-functioning who can be profession- can initially appear friendly and tuned in, social behavior or psychopathy.8,9 ally and socially successful, as well as but gradually become strikingly distant Currently, there is evidence within four those with functional impairment, with and aloof. Some can be modest and unas- areas of relevance for NPD that can fur- severely disabling narcissistic traits and suming with an air of grace. Still others ther guide the discussion about the diag- character functioning or accompanying present as perpetual failures, while con- nosis of NPD and its delineating criteria. Axis I disorders. stantly driven by unattainable, grandiose Regulatory patterns in pathological nar- There are several possible explana- aims. One can be shy and quiet, another cissism can be identifi ed within a range tions to the high functional ability in charming and talkative, yet another dom- of narcissistic features. The range of people with NPD. One suggests that ineering, aggressive, and manipulative. function, phenotype, changeability, and they can appear stable stoic, rigorous, Absence of symptoms and experiences empathy in NPD will be discussed and and organized despite internal dysregu- of suffering can be a paradoxical blessing integrated into reformulations of charac- lation, hyperreactivity, and fl uctuations. for some people with NPD while others teristics that can represent, describe, and Their surface functioning and absence are prone to depression, substance use, help understand people with disordered of symptomatology, combined with in- mood swings, or eating disorder. Some narcissism and NPD. terpersonal distance and diffi culties with people effectively hide their narcissistic self-disclosure, may support their internal aims, while others openly and bluntly ex- THE FUNCTIONAL RANGE control and allow their internal suffering hibit their most extreme narcissistic char- The variable prevalence rates of NPD to remain bypassed or hidden. Another acteristics. Nevertheless, the underlying in different settings imply a functional suggests that people with NPD cause dis- commonality is that they all struggle with range in people given this diagnosis (see tress, pain, and suffering in others while grandiosity, self-esteem fl uctuations, Table 1). Several studies have indicated they themselves are oblivious and do not limitations in their interpersonal relation- functional impairment and mental dis- experience their own suffering. Those ships, and intense emotional reactions to ability, especially when co-occurring without accompanying Axis I disorder threats to their self-experience. with major Axis I disorders such as sub- who also can avoid professional or per- Empirical studies have supported the stance use and mood and anxiety disor- sonal failure may not experience psycho- clinical observations that pathological ders.10-12 A recent study, Wave 2 National logical stress at all.10 narcissism can be expressed in temporary Epidemiologic Survey on Alcohol and A third explanation relates to the range of traits or in a stable, enduring personality Related Conditions (NESARC),13 found narcissism from healthy and extraordinary disorder. It can be identifi ed as symp- a lifetime prevalence rate of 6% (7.7% for to pathological and malignant.14 Co-exis-

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33903Ronningstam.indd903Ronningstam.indd 111212 33/11/2009/11/2009 3:27:513:27:51 PPMM tence of and fl uctuations between healthy his numerous psychotherapists about his Outstanding for the Arrogant type is and pathological aspects and functions of outstanding accomplishments. Convinc- the more striking predominant presenta- narcissism are common. Narcissistic in- ingly outlining his passion from beauty tion, with openly featured expressions dividuals may have strengths and abilities and design, he described a project he of self-serving and enhancing behaviors in certain areas (ie, in their professional or had done in a residence owned by the and attitudes in their more active and de- social lives), which can help sustain self- Dutch royal family and another owned liberate interactions with others. This is esteem regulation and interpersonal func- by a famous Hollywood fi lm director. in contrast to the inhibited, shame-rid- tioning, but still present with severe vulner- Further exploration revealed that at both den, and hypersensitive shy type, whose abilities and narcissistic patterns in other occasions he had been involved in ro- low tolerance for attention from others areas (eg, in their intimate relations, paren- mantic relationships with partners who and hypervigilant readiness for criticism tal roles, or moral and ethical standards or were designers and contracted to do these or failure makes him/her more socially behavior). Working capacity (ie, the ability projects, and that Mr. P’s role had been passive, tuned in, and interpersonally for sustained- and evidence-based voca- to assist with certain tasks while the re- awaiting. Nevertheless, under a modest tional or creative activities maintained over lationships lasted. When confronted with surface, the shy narcissistic individual is time and during phases of success as well the discrepancies in his accounts, he re- equally preoccupied with self-enhancing as when facing challenges and setbacks) is sumed to convincingly outline his inter- fantasies and strivings and hyperreactive a signifi cant indication of sustainable high- est in architectural and artistic beauty by to oversights or unfulfi lled expectations er functioning in people with NPD. Ability showing photographs of the interiors of from others. Contrary to the Arrogant for temporary achievements and a history exceptionally esthetic and artistically de- type who has more compromised, incon- of occasional or irregular accomplishments, signed buildings he had visited. sistent, or fl uctuating super-ego ranging or a one-time top achievement under favor- from perfectionism to temporary corrup- able circumstances, can indicate an actual THE PHENOTYPIC RANGE tion/deceitfulness, the shy type suffers or potential capability that is hampered by Several clinical accounts and studies from more strict conscience, harsh self- narcissistic fl uctuations or vulnerabilities. have suggested a two-cluster or two-fac- criticism, and feelings of guilt. In others, such fl eeting achievements can tor structure indicating two phenotypes A third and more outstanding presen- be the results of temporary self-enhanc- of NPD. This was initially suggested by tation includes narcissistic people within ing and self-serving behavior with little or Akhtar and Thomson15 and further dis- the range of antisocial personality disor- no accompanying capability or potential. cussed and confi rmed by several other der, psychopathy, and malignant narcis- Such differences are noticeable in the fol- authors.16-20 Empirical studies have also sism,8,30 characterized by aggression and lowing examples. supported such subtypes.21-26 Despite their hostility, or by cruel, sadistic, and destruc- After graduating from college Ms. A descriptive variations, a phenotypic range tive criminal or violent behavior. Typi- protested against her professionally ac- within different and opposite sets of nar- cally, such behavior serves to protect and complished and demanding parents by cissistic personality traits is indicated: one enhance the narcissistic individual’s self- working as a taxi driver. While driving arrogant, overt, grandiose, assertive, and esteem and can be driven by envy, entitle- in the city, she observed the architec- aggressive, and another shy, covert, vul- ment, vengefulness, or sadism, combined tural construction of several of the new nerable, insecure, and shame-ridden. As with severely compromised empathic buildings. Increasingly fascinated by en- with the functional range, the individual functioning (ie, when empathic ability is visioning architectural novelties and by presentation can include traits and patterns connected to exploitive ambitions). the idea of herself as a designer of excep- of both phenotypes (ie, the narcissistic in- tional interiors and exteriors, she studied dividual may fl uctuate between assertive FLUCTUATIONS AND architectural design on her own, formed grandiosity and vulnerability with shame- CHANGEABILITY a team of artists and contractors, and im- driven aggressive reactions).27 In the Psy- Fluctuation in narcissistic character plemented her ideas in a few buildings. chodynamic Diagnostic Manual (PDM)28 functioning, especially grandiosity, and After a period of successful collabora- the two subtypes of NPD, P104, are labeled changeability both toward improvement tion and production, her business ran Arrogant/entitled and Depressed/depleted. and worsening is the third area of studies into fi nancial diffi culties. In the context People with narcissistic withdrawal or neg- with relevance for the diagnosis of NPD. of being denied a bank loan, she barely ative narcissism as suggested by Green,29 A follow-up study showed overall im- survived a serious suicide attempt. with a state of emptiness, nothingness, or provement with less pathological narcis- Mr. P, a very smart, articulate, and even chronic suicidality, may be included sistic traits and diagnosis after 3 years.5 It laid-back middle-aged man, told one of in the latter category. also suggested that grandiosity, the core

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33903Ronningstam.indd903Ronningstam.indd 111313 33/11/2009/11/2009 3:27:513:27:51 PPMM trait and the most distinguishing and dif- THE RANGE OF EMPATHIC agency and separateness from the other; ferentiating characteristic for NPD, is re- FUNCTIONING mental fl exibility includes the ability for active and state-dependent. For instance, Empathy, usually considered an inborn perspective-taking and adopting the oth- it can be infl uenced by brief depressive and naturally occurring ability, is also a er’s subjective perspective; and emotional reactions or depressive disorder causing a complex, multidimensional regulatory regulation holds emotional resonance more self-critical and humble attitude, or process that requires skills, tact, and ex- and reappraisal. Self-awareness and self- by moving from late adolescence to adult- perience. Empathy is an essential aspect regulation are also central components in hood with experiences of more realistic of self-esteem regulation, and it is crucial empathic functioning. Those require sev- achievements and interpersonal experi- for the ability to master interpersonal re- eral abilities (ie, to identify and feel one’s ences that stabilize self-esteem. Sudden lationships and social interactions. Com- own emotions and separate oneself from threats to self-esteem or to more favor- promised or fl uctuating empathic process- one’s own feelings); to recognize the other able self-images can temporarily increase ing is basic to pathological narcissism and person as similar to one’s self but at the defensive grandiose behavior, such as an- NPD. Recent studies on empathic func- same time as separate and different from ger and hostility.31,32 Alternatively, such tioning have implications for identify- one’s self; and the ability to regulate and threats can cause a loss of self-esteem ing, understanding, and treating empathic inhibit one’s own emotional expressions. with shame and detachment.33 A continu- defi cits in narcissistic patients. Fonagy38 suggested empathy dysfunction ous search for others’ affi rmation of the Social psychological research has can stem from impaired capacity to un- grandiose but vulnerable self is typical, as identifi ed empathic regulation in terms derstand own feelings and disconnected is the use of interpersonal self-regulatory of cognitive empathy (perceiving the ex- interpersonal affective interpretative func- strategies such as self-enhancing behav- pression in others and theory of mind) tion, which are essential in emotional reso- ior and blaming others for failures. On the and emotional empathy (affective recog- nance. Low affect tolerance, or strong re- other hand, corrective life events, such as nition of the emotions perceived in oth- actions to the perception of the feelings of achievements, relationships, and manage- ers). Both empathic accuracy and em- others, especially helplessness and shame, able disillusionments, can contribute to a pathic concern are involved in empathic tend to impair capacity for empathic con- more realistic alignment of the self-es- regulation and both can vary indepen- cern.39 On the other hand, self-serving and teem and of the evaluation of the person’s dently35 (ie, an individual can present with self-enhancing strivings also interfere with own capacity and potential.5 In addition, empathic accuracy in the absence of em- empathic capability.40 In addition, empa- life events such as losses and narcissistic pathic concern, and vice versa). Netzlek thy is modulated by cultural values and injuries can also promote disengagement and colleagues36 suggested that people personal, developmental experiences. from inhibitions and can lead to meaning- have dispositional ability to be empathic ful engagements and self-representational (ie, to perceive and experience the emo- Empathic Variations in change in the context of achieving more tions of others), but situational factors can Psychiatric Samples realistically anchored ego-ideals.34 infl uence, or even overwhelm the expres- Studies of empathic functioning in Depression and anxiety, not endem- sions of such abilities. They concluded: psychiatric samples can provide some ic to NPD but resulting from problems, “… the capacity to experience empathy information relevant to understanding failures, or realizations of their own in the right contexts can be viewed as a the narcissistic individual’s empathic limitations, may also cause changes skill or ability rather than an automatic, abilities and limitations. People with in narcissistic individuals’ general dispositionally driven process … Such an autism have diffi culties with “cognitive functioning.10 Stress associated with ability is likely related to people’s ability empathy” (ie, perceiving the expression external experiences can escalate nar- to regulate their emotions.”35 in another person’s face). They also have cissistic symptoms and functioning, Empathy refers to the ability to perceive problems with empathic accuracy, (ie, to overwhelm the self, and trigger symp- the inner psychological state of others and accurately infer or even recognize the ex- toms such as shame, humiliation, and to identify and feel the feelings and needs istence of others’ thoughts and feelings). rage. Although underlying vulnerabil- of other people. Decety and colleagues37 However, variations in empathic ability, ity to such stress can stem from the identifi ed four neuropsychological com- especially empathic accuracy, have been presence of pathological narcissism or ponents involved in empathic capability: found along the autism spectrum.41 Pa- NPD, even relatively healthy people affect sharing is based on the ability to tients with schizophrenia have a general can develop narcissistic symptoms af- mimic and the development of shared rep- empathic defi cit manifest across all do- ter experiencing more or less severe resentations between self and others; self- mains of empathy-related processes.42 narcissistic threats or humiliation.6 other awareness requires a sense of self- However, notable variations are related

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33903Ronningstam.indd903Ronningstam.indd 111414 33/11/2009/11/2009 3:27:523:27:52 PPMM to the symptoms and source that cause consideration of the feelings and choices certain emotions in others, such as de- a specifi c defi cit. For instance, patients of others and which at times causes di- spair, sadness, grief, joy, happiness; or with schizophrenia with paranoid symp- rect emotional and/or physical harm to diffi culties in tolerating, modulating, and toms are hypersensitive to threats and others”).46 Similarly, Wiehe47 found an processing certain of one’s own emotions therefore likely to misinterpret others’ inverse correlation between empathy and triggered by the perception of others’ facial intentions and expressions. On the need for power, control, and dominance experiences or emotions, such as strong other hand, an inability to feel what the in child abuse perpetrators. negative feelings of contempt, shame, others feel (affective blunting) can also rage or envy); lead to a misidentifi cation of others’ fa- c) Self-esteem dysregulation, where cial expressions. the perception of others’ experiences Blair and colleagues43 found a high evoke self- promoting or self-enhancing degree of selectivity in empathic func- strivings, or alternatively, feelings of in- tioning in people with psychopathy. They feriority, powerlessness; and concluded that while these people have d) Superego dysregulation, with com- an impaired ability to process selective promised ability for care and concern, emotional expressions (fear, sadness, dis- exploitative efforts, disregard for the pos- gust), there is no evidence that they have sessions, and well-being of other people, a cognitive or “theory of mind”-related or deceitfulness. empathic impairment. Similarly, studies Narcissistic people may be able to ap- of empathic functioning in people with propriately empathize when feeling in antisocial personality disorder (ASPD) control or when their self-esteem is un- also show that they do not have basic challenged or promoted. Some can em- “cognitive or “theory of mind” defi cits, Sudden threats to self- pathize more with others’ positive feel- or diffi culties reading basic or complex ings and success-related experiences than emotions from facial expressions. In- esteem or to more favorable with others’ negative feelings or defeats stead, their problems refer to their ability self-images can temporarily and vice versa. Those infl uenced by envy to make empathic inference about how can be unable to tolerate others’ positive others feel.44 Patients with borderline per- increase defensive grandiose events and feelings, while those who sonality disorder (BPD) have been con- tend to mirror themselves in the light of sidered above average in their ability to behavior, such as anger others may perceive others’ success as an infer others’ thoughts and feelings. How- and hostility. opportunity for self-enhancement. Simi- ever, Flury and Ickes45 challenged this as- larly, those who readily feel contempt sumption in a study of paired BPD–non- Implications for Empathic can fi nd others’ defeats and losses despi- BPD dyads whose ability to accurately Functioning in Narcissistic cable and secure their own superiority or read thoughts and feelings of each other Individuals perfectionism in the comparison between were measured. They concluded that Compromised empathic functioning self and the other. Others are able to em- people with BPD do not have empathic causing recurrent interpersonal failures pathize under certain circumstances (ie, impairment (ie, they are capable of pro- or confl icts can be a source of fl uctuating when asked for advice by a friend who cessing the complex borderline-related or low self-esteem and underlying inse- has marital problems, but unable to relate dysregulatory emotional experiences in curity. The narcissistic individual, ready to their own marital problems as pointed themselves and others, but they do not to blame others, may or may not be aware out by the spouse). A guide for evalua- have exceptional or above-average em- of such a defi cit. Several possible factors tion of the narcissistic patient’s specifi c pathic capability). may impact the narcissistic individual’s individual empathic defi cits and func- Conditions related to pathological empathic capability and functional pat- tional patterns is outlined in the Sidebar narcissism have been associated with low tern. Those include: (see page 116). levels of cognitive empathy (preoccupa- a) High degree of self-centeredness Empathic dysfunction and compro- tion with other things). Gilgun46 identi- and focus on self-enhancing and self- mised ability for empathic processing fi ed a high degree of self-centeredness in serving interpersonal strivings; can disable the narcissistic patient from perpetrators of child abuse (ie, “a focus b) Emotional dysregulation (ie, in- accurately perceiving and experiencing on the self so intense that it precludes sensitivity or impaired ability to appraise empathy from another person. This has

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33903Ronningstam.indd903Ronningstam.indd 111515 33/11/2009/11/2009 3:27:523:27:52 PPMM SIDEBAR. signifi cant consequences in treatment of control is a major obstacle in treatment of the narcissistic individual, who easily can the narcissistic patient55-57 and is expressed Narcissistic Empathic misinterpret the clinician’s genuine efforts in a range of attitudes and behavior — Functioning: Defi cits and to help. Glasser48 noted that: “Sometimes from self-assertive independence and self- Phenotypic Range the patient can actually experience empa- protection to dominance and power and to Developmental, Emotional, thy as a danger, since he feels the analyst critical, aggressive, sadistic intrusiveness. and Cognitive Defi cits is getting inside his mind and reading his In its ultimate form, narcissistic self- • Lack of motivation, curiosity, interest, or thoughts, and that the danger of being regulation with self-directed aggres- other-orientation/narcissistic withdrawal “brainwashed” is imminent.”48 sion and efforts to control, can also be (negative narcissism) expressed in suicidal ideations and acts, • Underdeveloped, self-other distinction IDENTIFYING REGULATORY representing a “my way or no way” or • Self-centeredness PATTERNS IN PATHOLOGICAL “death before dishonor” attitude. Studies • Emotional dysregulation, low-affect tolerance NARCISSISM have proved pathological narcissism to be 58-60 • Superego defi cits The self-regulatory approach to patho- connected to suicide. logical narcissism focuses on the self-es- Suicidal ideations and behavior can Phenotypic Range teem (ie, its range from assertiveness and serve to protect against threats or defeats, Detached Empathic Functioning grandiosity to inferiority or insecurity) represent an illusion of mastery, control, • Inattentive and on the various self-enhancing and or indestructibility, or they can serve as a • Obliviously insensitive self-serving interpersonal strategies that means to attack or destroy imperfect as- • Withdrawn aim at protecting and heightening self-es- pects of the self. Narcissistic individuals • Silent due to internal reactions: teem and grandiosity. Emotional dysreg- can have suicidal thoughts and impulses emotional fl ooding (aggression, shame); ulation is evident in the predominance of in the absence of depression, and they confusion; internal paralysis or numbness aggression and shame, the intense reac- can also balance suicide-related self-es- Self-enhancing Empathic Functioning tions to threats to the self-esteem, and the teem-preserving grandiose ideas on the • Tuned in, seemingly empathic individual’s efforts to maintain internal one hand and the actual suicidal behavior • Friendly, actively helpful, seemingly and external control. and its real self-destructive or lethal con- altruistic O. Kernberg49,50 suggested a motiva- sequences on the other.61,62 Intolerable ef- • Multiple-intellectual, perspective taking, tional function in aggression as an effect, fects, caused by threats to self-esteem, or seemingly refl ective because it links self-object representations loss of essential support or ideals, can be • Ambitiously intrusive, domineering, 30,33,63 or controlling, seemingly concerned, with internalized object relations associ- denied and split off. These regula- involved, and protecting ated with frustrating experiences. More or tory functions may make narcissistic indi- • Perfectionist attitude less primitive aggression, expressed either viduals reluctant (or even unable) to con- • Moral superiority or condemnation overtly toward others or internally, is the vey their suicidal intentions to a clinician. • Taking emotional or social advantage of self-regulatory process that contributes to a For some, suicidal ideations may even others’ feelings and experience sense of superiority. Kohut50,51 considered function as a way to control and process

Aggressive Empathic Functioning self-cohesiveness to be central for narcis- unbearable feelings and help the individu- 64 • Belittling, ridiculing sistic functioning. Several authors have re- al preserve connections to life. However, • Irritable cently recognized the narcissistic patient’s if acted upon in a state of rage or despair, • Resentful, rejecting preoccupation with control, both internal they may also cause instant suicide in rel- 52-54 • Critical, contemptuous and interpersonal. Internal control, a atively well-functioning individuals with- 58,65,66 • Retaliating, revengeful psychological function that promotes a out other major mental illness. • Hostile dismissive reactions sense of mastery, cohesiveness, power, separateness, and self-suffi ciency, includes FACING DSM-V Malignant Reactions to the Perception both the efforts to maintain a sense of con- The general limitations of DSM-Axis of Others’ Feelings and Experiences trol and an underlying fear of loss of con- II have been pointed out (ie, failing to • Manipulative deceitfulness trol. Fear of loss of control can be triggered capture the range of personality pathol- • Exploitive usage of empathic compe- tence for self-serving, perverse, sadistic, by internal as well as external experiences, ogy and identify patients whom clini- cruel, or antisocial aims especially related to sustaining meaning cians consider having personality dis- • Violent impulses or behavior and self-suffi ciency, and to avoiding emo- orders is particularly consequential for tional fl ooding and shaming. Interpersonal NPD).53,67,68 People with traits of patho-

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33903Ronningstam.indd903Ronningstam.indd 111616 33/11/2009/11/2009 3:27:533:27:53 PPMM logical narcissism that range beyond the and success fantasies, but is also expressed ity. Several accounts support the shifts in DSM-IV-text revision69 criteria set, or in terms of perfectionism and high ideals self-esteem-related internal experiences people who have less severe or less overt and is sustained through self-enhancing and overt expressions of grandiosity.5,31 narcissistic pathology and for various and self-serving interpersonal behavior. Vulnerability and insecurity have usu- reasons do not meet any combination of These reformulations serve to expand the ally been assigned to the range of NPD fi ve required criteria, will consequently spectrum of grandiosity-promoting striv- that includes the shy, covert, shame-rid- not be correctly identifi ed. ings and activities, capture its fl uctuations, den phenotype. However, such shifts in The current NPD criterion set has re- and attend to the narcissistic individual’s the arrogant aggressive phenotypic range peatedly been criticized for its low speci- internal experiences and motivation. may be easily bypassed or covered up, fi city with high diagnostic overlap and Independently of whether the future and only overtly occur in the context of comorbidity. The fact that the diagnosis DSM will remain categorical or move ultimatums or when feeling trapped with is heavily relying on overt and one-sided toward a dimensional perspective, the no way out, and then expressed in rage at- determinants of grandiosity and on con- conceptualization of NPD in terms of a tacks, retaliation, or suicidal behavior. text-dependent external symptoms or pat- range of narcissistic dysregulatory func- terns of reactions and interpersonal inter- tioning aims at improving clinical utility, 3. Strong Reactions to Perceived actions has contributed to this problem. promoting awareness, and understanding, Challenges or Threats In addition, the narcissistic individual’s and motivating and guiding treatment for to Self-esteem experiences of the complex interplay be- both clinicians and patients. Strong reactions in response to criti- tween self-esteem fl uctuations and emo- cism from others was included in DSM- tional dysregulation within the interper- ALTERNATIVE FORMULATIONS III72 and DSM III-revision but excluded in sonal context are not adequately captured. DSM IV73 because of its low discrimina- Consequently, there is reluctance among 1. Grandiosity tory power and overlap with other person- clinicians to use the diagnosis, and pa- Grandiosity is by now an evidence- ality disorders. Morey53 has convincingly tients tend to strongly oppose to being based criterion, and the most distinguish- argued for its reinstatement. This alterna- “labeled” NPD, conceiving it as more ing and discriminating for NPD.25,70,71 tive formulation, strong reactions to per- prejudicial than informative and helpful. However, it is also limited by the few ceived challenges,or threats to self-esteem An integrative diagnostic approach for external features assigned to it. The dif- attest to the narcissistic individual’s spe- pathological narcissism and NPD with al- ferentiation between enhanced compared cifi c self-esteem vulnerability and to the ternative formulations is much called for, with unrealistic sense of superiority, and threats or challenges that are perceived one that focuses more on basic indicators the inclusion of value, capability, and fan- as especially narcissistically threatening. for the range of narcissistic personality tasies of unfulfi lled achievements serve It also captures a pattern of emotional functioning and less on symptomatic fea- to capture a broader functional range of dysregulation. Mood variations as a sign tures or phenotypic categories (see Table narcissism and to make the diagnosis of narcissistic vulnerability and reactiv- 2, page 118). Such a diagnostic approach applicable to both those with NPD who ity refl ect shifting levels in self-esteem18 should evaluate basic characteristics of nar- are vocationally higher functioning and and are important in differentiating Axis I cissistic functioning, and differentiate tem- those who are disabled. For the purpose mood disorders. The concept “threatened porary fl uctuating or externally triggered of clinical utility, it is useful to evaluate egotism”32 suggests that such vulnerabil- shifts in narcissistic functioning from en- grandiosity not only in terms of its sur- ity and reactivity could make narcissistic during indications of pathological narcis- face expressions but also in the context individuals prone to more distress, such as sism. Regulation of self-esteem, a central of its functional base (ie, to differentiate depression, substance use, self-defeating part of self-regulation, is identifi ed as the unrealistic and defensive aspects of gran- or violent behavior, or suicidality. motivating force in narcissistic function- diosity and grandiose fantasies), from po- ing, and its vulnerability and fl uctuations tentially realistic competence and hidden 4. Self-enhancing Interpersonal are indicated by reactions to threats and or potential capability for factual or even Behavior challenges to the self-esteem (ie, the most successful abilities. The alternative formulation self-en- signifi cant trait of NPD; compare vulner- hancing interpersonal behavior integrates ability and reactions with abandonment as 2. Vulnerable and Fluctuating 3.5 of the DSM-IV-TR criteria. It aims at a central marker for borderline personality Self-esteem diminishing the previously heavy focus on disorder). A broader defi nition of grandios- Vulnerable and fl uctuating self-es- grandiosity-related features by highlight- ity captures not only a sense of superiority teem relate to changeability in grandios- ing its self-esteem regulatory and motiva-

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33903Ronningstam.indd903Ronningstam.indd 111717 33/11/2009/11/2009 3:27:533:27:53 PPMM TABLE 2. Diagnostic Criteria for NPD: DSM-IV-TR69 and Alternative Formulations

DSM-IV-TR NPD: Construct and Criteria Alternative Formulations: Construct and Criteria

A pervasive pattern of fl uctuating and vulnerable self-esteem ranging A pervasive pattern of grandiosity (in fantasy and behavior), need for admira- from grandiosity and assertiveness to inferiority or insecurity, with self- tion, and lack of empathy, beginning in early adulthood and present in a enhancing and self-serving interpersonal behavior, and intense reac- variety of contexts, as indicated by fi ve (or more) of the following: tions to perceived threats, beginning in early adulthood and present in a variety of contexts as indicated by fi ve (or more) of the following:

DSM 1. Has a grandiose sense of self-importance (eg, exaggerates achieve- 1. Grandiosity: enhanced or unrealistic sense of superiority, ment and talents, expects to be recognized as superior without commen- uniqueness, value or capability, expressed either overtly in unwar- surate achievements). DSM 2. Is preoccupied with fantasies of unlimited ranted expectations, exceptionally high aspirations, and self-centered- success, power, brilliance, beauty, or ideal love. DSM 3. Believes that he or she ness, or covertly in inner convictions, fantasies of unfulfi lled ambitions is “special” and unique and can only be understood by, or should be associ- or unlimited success, power, brilliance, beauty, or ideal relationships. ated with, other special or high-status people (or institutions).

2. Fluctuating and vulnerable self esteem, alternating between feel- ing overly confi dent or assured, and feeling inferior or insecure.

3. Strong reactions to perceived challenges or threats to self-es- teem (humiliation, defeats, criticism, or envy from others), including DSM 8. Is often envious of others or believes that others are envious of them. overtly expressed or covertly hidden intense feelings (aggression, envy or shame) or mood variations (irritability, depression or elation).

DSM 3. Believes that he or she is “special” and unique and can only be 4. Self-enhancing interpersonal behavior (ie, admiring attention understood by, or should be associated with, other special or high-status seeking, self-promoting, boastful, or competitive behavior). people (or institutions). DSM 4. Requires excessive admiration.

DSM 5. Has a sense of entitlement (ie, unreasonable expectations of 5. Self-serving interpersonal behavior (ie, expecting unreasonable especially favorable treatment or automatic compliance with his or her and unwarranted rights and services and unreciprocated favors from expectations). DSM 6. Is interpersonally exploitive (ie, takes advantage others, or taking emotional, intellectual and social advantage of others). of others to achieve his or her own ends).

6. Interpersonally aggressive (ie, arrogant, critically argumentative, DSM 9. Shows arrogant, haughty behaviors or attitudes. resentful, hostile, or passive-aggressive).

7. Interpersonally controlling (ie, domineering, distant or uncommit- ted interpersonal behavior that serves to avoid intolerable affects or threats to self-esteem).

8. Fluctuating or impaired empathic ability, compromised by DSM 7. Lacks empathy: is unwilling to recognize or identify with the self-centeredness, self-serving interests, or emotional dysregulation feelings and needs of others. (low affect tolerance or intense reactions, ie, shame, envy, inferiority, powerlessness, anger).

9. Exceptionally high or perfectionist (although inconsistent) personal ideals and standards, with strong reactions, including aggression, harsh self-criticism, shame, or deceitfulness when failing to measure up.

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33903Ronningstam.indd903Ronningstam.indd 111818 33/11/2009/11/2009 3:27:533:27:53 PPMM tional functions, and broadening the range ent components; (ie, uncommitted,71 con- unreachable to him within his marriage. of behavior that the individual can use for trolling/hostile,53 dominance to manage Playing with infi delity and dishonesty, self-enhancing purposes. hostility and protect self-esteem;78 control- he struggled with underlying self-critical ling/competitive54,79,80).Attention to these attacks for being an imperfect, dishonest 5. Self-serving Interpersonal underlying regulatory mechanisms of husband, which tended to escalate his de- Behavior emotions and self-esteem serve to differ- sire for more ecstatically perfect erotic ad- Self-serving interpersonal behavior is entiate pathological narcissism and NPD ventures. The narcissistic individual’s in- an integrative formulation capturing types from more psychopathic and malignant ternal underlying self-shaming84 and harsh of behavior previously referred to as en- interpersonal behavior. or punitive self-criticism is often bypassed titlement and exploitation. With its normal or externalized during evaluation and treat- developmental and social/political conno- 8. Fluctuating or Impaired ment because it may be expressed as self- tation, entitlement can be misleading as a Empathic Ability depravation or excessive entitlement.85 diagnostic criterion. To be non-entitled or Fluctuating or impaired empathic abil- score low on entitlement does not neces- ity, infl uenced by emotional dysregulation SUMMARY sarily indicate a healthy narcissistic func- (low affect tolerance or intense reactions) Facing the process of outlining and tioning, and strikingly entitled behavior and/or self-centeredness or self-serving deciding the new DSM-V, there are a few may stem from an underlying sense of interest, is a reformulation of the seventh major incentives with regards to the future being undeserving, with restricted entitle- of the NPD criteria in DSM, based on the NPD diagnosis. The fi rst concerns the self- ment or even feeling nonentitled.74 Where review of research on empathy presented. regulatory nature of narcissistic function- normal or exceptional rights and expecta- The differentiation between actual and im- ing and its focus on self-esteem and inter- tions end and unrealistic expectations take paired capability and between temporarily personal control. The second relates to the over with exaggerated and overbearing in- interfering and persistently dysregulatory clinical range of pathological narcissism, terpersonal demand, intense reactions can characteristics are specifi cally important including both the enhanced, seemingly in- vary with individual contexts and cultures. for choice of treatment approach and mo- violate grandiosity, as well as the fl uctuating Exploitative behavior failed to differentiate dality, and for prognosis. and vulnerable nature of self-esteem with NPD in previous studies.71,75-77 Narcissistic its opposites — inferiority and insecurity. exploitative behavior is distinguished by a 9. Exceptionally High or Perfectionist The third is the underlying reactivity and more passive, manipulative, entitled, and Personal Ideals and Standards sensitivity to threats (ie, potential defeats emotionally focused quality that serves to A complex interrelation between ego- or depreciation of self-esteem), and vari- support and enhance self-esteem. ideals, self-esteem regulation, self-criti- ous self-serving and self-enhancing striv- cism, and deceitfulness can be found in ings to protect or heighten the internal and 6. Interpersonal Aggression narcissistic individuals. Some can be external value of the self. The fourth refers Depending upon the narcissistic indi- found among those who openly take pride to reevaluation of the empathic functioning vidual’s ability for emotional regulation in their superior and perfectionist stan- and the variable, context-dependent defi cits and interpersonal skills, interpersonal ag- dards and ideals.81-83 Such perfectionism in empathic ability. This review has aimed gression can range from subtle arrogance, can coexist with incompatible, inconsis- at summarizing, reformulating, and outlin- argumentativeness, or resentfulness to vari- tent, and contradictory moral standards. ing a proposal for a diagnosis and set of de- ous expressions of passive-aggression to For example, a married, middle-age man scriptive criteria for NPD accordingly. more strikingly hostile, enraged behavior, who took pride in being monogamous or outbursts. Such outbursts can also stem was bothered by what he considered to REFERENCES from underlying feelings of shame, envy, be his wife’s imperfect physical appear- 1. Akhtar S. Narcissistic personality disorder: de- scriptive features and differential diagnosis. Psy- inferiority, diffuse guilt, or fear. ance. Feeling compelled and justifi ed to chiatr Clin North Am. 1989;2(3):505-530. approach perfect-looking young women 2. Cain NM, Pincus AL, Ansell EB. Narcissism at 7. 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