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 PSYCHIATRIC ANNALS 39:3 | MARCH 2009 PsychiatricAnnalsOnline.com | 111 33903Ronningstam.indd903Ronningstam.indd 111111 33/11/2009/11/2009 33:27:47:27:47 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- 112 | PsychiatricAnnalsOnline.com PSYCHIATRIC ANNALS 39:3 | MARCH 2009 33903Ronningstam.indd903Ronningstam.indd 111212 33/11/2009/11/2009 33:27:51:27:51 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