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Journal of Personality Disorders, 25(2), 248–259, 2011 © 2011 The Guilford Press

Narcissistic Personality Disorder in DSM V—In Support of Retaining a Significant Diagnosis
Elsa Ronningstam, PhD

Narcissistic personality disorder, NPD, has been excluded as a diagnostic category and independent personality disorder type in the Personality and Personality Disorder Work Group’s recent proposal for DSM-5 Personality and Personality Disorders. The aim of this paper is to pre­ sent supporting evidence in favor of keeping NPD as a personality type with a set of separate diagnostic criteria in DSM-5. These include: the prevalence rate, extensive clinical and empirical reports and facts, its psychiatric, social and societal significance especially when associated to functional vocational and interpersonal impairment, social and moral adaptation, and acute suicidality. Proposals for a clinically relevant and empirically based definition of narcissism, a description of the narcissistic personality disorder type, and a set of diagnostic criteria for NPD are outlined.

The transformation from psychoanalytic theory and descriptions to meet standards for taxonomy and inclusion in the DSM III in 1980 initiated a complicated process of formalizing the concept of narcissism and defining the diagnosis of narcissistic personality disorder, NPD. The limitations of DSM- Axis II diagnosis, in particular the failure to capture the full range of personality pathology and identify patients whom clinicians consider having personality disorders diagnosis, have been especially consequential for NPD (Morey & Jones, 1998; Gunderson, Ronningstam, & Smith, 1996; Westen & Arkowitz-Westen, 1998). People with traits of pathological narcissism that range beyond the DSM criteria set, or people who have less severe or less overt narcissistic pathology and do not meet any combination of five required criteria, will consequently not be correctly identified. In addition, central aspects of the clinical base for identifying pathological narcissism and NPD, including the individual’s internal distress and often painful experiences of self-esteem fluctuations, self-criticism, and emotional dysregulation within the interpersonal context, are not adequately captured. Russ, Shedler, Bradly, and Westen (2008) found several aspects of personality functioning and internal experiences not captured in the DSM criteria, such as interpersonal vulnerability, emotional distress, and
From Harvard Medical School, McLean Hospital. Address correspondence to Elsa Ronningstam, PhD, Harvard Medical School, McLean Hospital, Belmont, MA; E-mail: ronningstam@email.com

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the academic and the clinical. and NPD can now frequently be found in journals of clinical psychology. In clinical psychology and psychiatry the studies of NPD as a pervasive personality pattern of grandiosity (in fantasy and behavior). Prevalence and Clinical utility The information regarding the prevalence and clinical utility of NPD based on the DSM criteria set has so far been evaluated in ways that often fail to take into account the range of functioning and phenotypic presentations . & Ansell. Hence. 2005.. Campbell. 2002. and interpersonally conspicuous behavior. 1991). Ronningstam. social.. 2008. Wasserman. Gunderson. 2009). Pincus and Lukowitsky (2010) concluded that “relying solely on the DSM-IV criteria may impede clinical recognition of pathological narcissism” (p. Studies in support of identifying.. 2007. There is a call for integration and applicability of the vast accumulated knowledge on narcissism and NPD. While not associated with societal urgency or notable public or mental health costs. Volkan & Fowler. need for admiration and impaired empathic ability have. conceiving it as prejudicial. have remained relatively separate. Research in the academic social and personality psychology have identified trait narcissism in nonclinical samples. Torgersen. validity (Gunderson & Ronningstam. 2005a. factor analytic structure (Fossati et al. Pincus. 2008). 2009. Miller. diagnosing and treating pathological narcissism. 2009). 430). With this briefly summarized background the purpose of this article is to oppose the DSM-5 Personality and Personality Disorder Work Group’s proposal to exclude NPD as a separate personality disorder type and critique the diagnostic approach to and suggested traits for NPD. & Pilkonis. This has contributed to a considerable discrepancy between the clinicians’ definition and usage of the NPD diagnosis compared to the official criteria set. 2010. With the DSM’s heavy reliance upon grandiosity and external. Campbell. there is reluctance among clinicians to use the diagnosis. and changeability (Ronningstam. heritability (Torgersen et al. despite the limitations in clinical applicability and utility of the diagnosis. Penny & Spector. Stone. & Lyons. recent efforts to integrate and find common denominators are most important and promising (Pincus et al. 1998. Levy. & Cramer. 2008. 2000). NPD has still met increasing recognition as an urgent and complicated mental condition connected to significant personal. Several reviews have summarized the accumulated evidence relevant to present and future diagnosis of NPD (Cain. Hoffman. and patients strongly oppose being “labeled” NPD. Reynoso. the diagnosis has not been informative and guiding. Although the two avenues of studies. Kringlen. Miller. psychiatry. 1995). especially its impact on Axis I disorders and suicidality. & Pilkonis. still verified its prevalence (Stinson et al. and work-related problems with organizational and societal consequences (Maccoby. 2007.. interpersonal.RETAINING A SIGNIFICANT DIAGNOSIS 249 affect dysregulation. & Clarkin. Ronningstam & Maltsberger. and psychoanalysis. 2009. Pincus & Lukowitsky. 2000. 2001). 2010).

In addition. & Pilkonis. self-directed empathy. The discrepancy between their interpersonal appearance and relatedness (Ogrodniczuk.. and their internal experiences and reasoning (Horowitz. Rhodewalt & Eddings. 2009).. with up to 20% in specific populations. (2007). & Lyons 1995. and only be evident under certain circumstances.e. Wasserman. avoidance. reasons for seeking psychiatric treatment or psychotherapy most often relate to external life crises and onset or aggravation of Axis I disorders. 2009). 2007). memory functioning.. Rhodewalt. 2008). (Kernis & Sun. 2009). there is significant evidence in support of an adequate prevalence rate. Simon. Nevertheless. Chauhan. or an acute onset of Axis I disorder(s) (Ronningstam. shame. This has also invited to an over reliance on external behavioral traits and indications of exaggerated self-esteem as the base for diagnosis. interpersonal reactivity. 1996. eating disorder. a personal crises. semi-structured interviews. & Duggal. higher prevalence rates have been found in studies using clinicians’ ratings (Levy. Clarkin. or to complaints or ultimatums from family or employers associated with sometimes limited sense of own suffering or contributions to others’ distress (Miller. and denial (Horowitz. Laboratory studies have succeeded in identifying numerous specific patterns relevant for narcissistic functioning in nonclinical samples. a corrosive life event. self-enhancement. observer ratings) and the way that specific narcissistic functioning and NPD features can be accurately captured versus underestimated or even bypassed by each method. The actual narcissistic pattern or potential for developing a personality disorder may not be fully manifested in higher functioning people until there is a change. In functionally disabled people the predominance of Axis I symptomatology may overshadow the narcissistic personality functioning. depressive disorder or atypical mood disorder (Ronningstam. There are specific difficulties identifying narcissistic personality functioning when co-occurring with Axis I disorders with predominant symptomatology such as substance use. Even in such cases. Gunderson. Steinberg. the differentiation of Axis I symptoms from narcissistic personality traits and the identification of the NPD diagnosis. and accompanying compromised abilities for selfevaluation. 6% life time in general population (Stinson et al. emotional dysregulation. mood variability. There are reasons to assume that prevalence rates of NPD have been influenced by research methods (self-reports.e. Simonsen & Simonsen. self-esteem instability. Joyce. justifying the inclusion of NPD in DSM-5 (for detailed review of prevalence see Ronningstam (2009) and Levy et al. i. 2001). certainly both limit and bias accurate diagnostic evaluations based on self-rating and interpersonal disclosure.250 RONNINGSTAM in narcissistic people. bipolar spectrum disorder. etc. For instance. Piper. such as control. & Reyonoso. may be challenging and require longer and more in-depth contact in a treatment setting. 1994. Cambell. 2002. especially anger and aggression. i. Man- . combined with limitations in their willingness or ability for self-disclosure. and self-disclosure. 2010). 2009). Other methods for rating are more reliant upon the narcissistic individuals’ specific protective and regulatory patterns..

including a regulatory role and a functional range. Salvatore. 2001. are notable and promising (Pincus et al. 2008).RETAINING A SIGNIFICANT DIAGNOSIS 251 drian. 2007. In the field of personality psychology efforts to develop a construct and measure of pathological narcissism to complement and integrate with the accumulated number of studies on narcissism within the relatively functional range. as a separate personality disorder type . 2008. Jorstad. 1998) has been relatively well integrated in the proposed 5 levels of personality functioning (Bender. and empathic capability (Ronningstam. 2004) and most significant for accurately diagnosing the fluctuating and regulatory empathic patterns of NPD. A number of studies within several areas of inquiry have recently added substantial knowledge on pathological narcissism and NPD. Maldonado.. NPD in the DSM-5 Proposal While narcissism as a dimension for general personality functioning is incorporated in the proposal for DSM-5 personality disorder section. Studies in metacognitive therapy have identified states of mind. 2007. (3) five major personality disorder types described. (2) five levels of self and interpersonal personality functioning (degree of impairment). and (4) 37 personality trait facets organized under six personality trait domains (see: www. interpersonal affiliation and relativeness. 2009. Variable range of self and self-esteem from aggrandizement to deflation and self-loathing. NPD. Fiore. control and self-protection on the evaluation of task performance and situational experiences.dsm5. 1998. Such studies have been designed in ways that lessen the restricting impact of narcissistic avoidance. and dysfunctional dialogues and interactional patterns in people with NPD that negatively affect the therapeutic alliance (Dimaggio. & Carcione. Ryder. 2003). Of specific importance is the Work Group’s acknowledgment of empathic capability as a skill with several components.. 2006). unrealistic expectations of others. self-coherence. This is in line with recent research (Decety & Jackson. More comprehensive and clinically diversified portraits of NPD have been obtained through clinicians’ ratings (Russ et al. narcissistic personality disorder. 2010). The DSM-5 Proposal for Personality Disorders The proposed model for personality disorders in DSM-5 have four components: (1) four general diagnostic criteria for personality disorders. Ring. & Cheney. Dimaggio et al.org). Narcissism as a general dimension for normal personality functioning. Psychoanalytic case studies and detailed narratives of treatment process and technique have served to inform about how specific narcissistic personality patterns interact with therapeutic interventions (Almond. and exaggerated personal standards are indications of mild to severe levels of impairment in general personality functioning.. Dimaggio et al. Twenge & Campbell 2003). 2005b. & Pincus. 2004. Stone. 2010). Tritt. including regulation of self and self-esteem. 1999. uniqueness.. Kernberg.

General limitations in the DSM-5 Proposal affecting NPD While the DSM-5 Work Group have outlined an ambitious proposal for diagnosing personality disorder that adhere to some of the advanced theoretical and empirical standards in the field. and Anxiousness). Ronnings- . There are several serious problems and disadvantages with regards to identifying and diagnosing pathological narcissism and disordered narcissistic personality functioning with the present proposal. 2009. there is a striking and significant lack of integration of clinical knowledge and applicability. 4. and the gap between the suggested personality types.. constructing or covering a diagnosis based on separate traits from different domains shared by other personality types. included under the trait domain Antagonism. i.. Unfortunately. NPD has been replaced by four personality trait facets: Narcissism.  Weaken or disrupt the promising work in progress on developing treatment strategies for people who indeed suffer from pathological narcissism and NPD. Shame. the radical changes compare to the previous DSM systems. Depressivity.e. traits and models.e. Manipulativeness. (i..252 RONNINGSTAM and diagnostic category has been excluded. and Compulsivity..e. 3. The proposal also represents an effort to reduce and streamline the diagnostic criteria for personality disorders. Other traits that clinically and empirically have been associated with NPD can be found under the domains Negative Emotionality. the complicated structure of the proposed system.  Undermine or prevent ongoing and future efforts to identify narcissism and NPD relevant to clinical studies and utilization. and Callousness. 2010) highlights some of the major difficulties. marital and work related to severe psychiatric conditions such as suicide (Blasco-Fontecilla et al. Histrionism. and clinical practice and utility. 2010). Kernberg. Perfectionism.  Discourage or eliminate the connection of NPD as a significant triggering or accompanying factor in a range of problems from interpersonal.. prevents an integrated and specific. Russ et al. This is a remarkable and most consequential decision. (i. The elimination of NPD as a separate personality disorder type and the idea of replacing it with a set of unconnected and unintegrated traits will risk to: 1. Low SelfEsteem. In the proposed system. this ambition has specific consequences for NPD as some of the most important facets and traits of NPD (Morey & Jones.. 2001. i.e. clinically-meaningful and informative conceptualization of narcissistic personality functioning which is necessary to further improve its clinical utility.  Complicate or discourage a proactive and informative usage of the NPD diagnosis 2. 1998.. Bender. This scattered trait approach. 2008) will not be included. Critique towards the overall proposal stated elsewhere (Gunderson et al.

1990.RETAINING A SIGNIFICANT DIAGNOSIS 253 tam. Ronningstam & Gunderson. Cooper. there is evidence supporting cognitive empathic capability in both narcissistic and antisocial personality disorders.” This is neither clinically meaningful nor empirically representative. Hadar. especially the efforts to sustain interpersonal control.” Callousness is representative of one segment in the range of phenotypic presentation of severe NPD. 1989. either overtly interpersonally or behaviorally expressed or internally hidden. and self-preoccupation with self-enhancing and self-serving interpersonal behavior. and homicidal behavior (Schlesinger. Narcissism and NPD in the Antagonism Trait Domain The proposed conceptualization of NPD using four traits. 2001). Callousness. The following alternative formulation takes into account both the regulatory function of narcissism and the individual’s internal experiences relevant for a definition of narcissism in the context of outlining mental disorders and defining psychiatric diagnosis: “Enhanced or unrealistic. narcissism is defined as “Vanity/boastfulness/ exaggeration of one’s achievements and abilities. Manipulativeness captures some essential aspects of narcissistic interpersonal functioning.. firmly holding the belief that one is better than others and deserves only the best of everything in life. and intense reactions to threats. Narcissism. People with mild to moderate severity of NPD do not have such degree of superego pathology as they usually have capacity for guilt and remorse (Kernberg. 2001). criticism or defeats. rather than the self and self-esteem regulatory aim found in people with NPD. Simon. In addition. 2009). and posttraumatic stress reactions (Bachar. 2008).. Stone. sociopathic. as outlined in the DSM-5 proposal. Histrionism describes histrionic personality traits. 2005. Lacking both empirical and clinical relevance. 2008). the malignant antisocial/psychopathic.e. & Shalev. this trait combination will steer the definition and diagnosis of NPD towards external features representing predominantly antisocial/sociopathic or histrionic personality functioning. vulnerable and variable self-esteem with self-criticism and inferiority. psychopathic. self-centeredness. 2004. 1998. Ritter et al. 1984). it indicates more of the active calculating incentive typical for the antisocial/sociopathic personality. but their emotional empathic capability varies depending upon their degree of severity of NPD and their ability for emotional and self-esteem regulation. Kernberg. indicating empathy as a capability with a range of functional and situational variability (Dolan & Fullman. and Histrionism does not represent the empirically-defined or clinically-derived description of NPD (Akhtar. i. Manipulativeness. On the DSM-5 website. People with NPD do indeed have cognitive empathic capability. 2009. i. & Maltsberger. sense of superiority and exaggeration of own achievement and capability. However..e. 1998. Russ et al. feeling and acting entitled.. Weinberg. which may to some .

and its vulnerability and fluctuations are indicated by reactions to threats and challenges to Table 1.e. 5. fluctuating. overtly expressed or internally concealed interpersonal argumentative and critical. mood variations (irritability. Impaired empathic ability—inconsistent and compromised by self-centeredness. see Table 1). Avoiding—i. envy. controlling behavior that serves self-esteem regulation and protection of grandiosity.. criticism. serve and enhance internal control and self-esteem (Ronningstam. Perfectionism—exceptionally high or inflexible (although inconsistent) ideals and standards of self or others. boastful. Aggressive—i. 8. including aggression. is identified as the motivating force in narcissistic functioning. resentful. i. exceptional or unrealistically high aspirations. Reactions to perceived threats to self-esteem—(humiliation. self-promoting. with strong reactions. Self-enhancing interpersonal behavior—i. or ideal relationships. vulnerability. inferiority..254 RONNINGSTAM degree occur within the phenomenological range of NPD. Such features attend to self-esteem regulation and the associated variability. 1998). cruel or sadistic.. 6. expressed either overtly in unreasonable expectations. intellectual. failing to reciprocate favors from others (entitled). 7. Grandiosity—enhanced or unrealistic sense of superiority. and of inferiority and insecurity 3. selfserving interests or emotional dysregulation (low affect tolerance or intense reactions. passive-aggressive. or deceitful or retaliating behavior. and internal painful feelings and experiences. as well as the various efforts to protect. 9.e. failures) including intense feelings (overt or covert anger/hostility. or capability. hostile. the underlying dynamic and interpersonal behavior and intent are quite different in histrionism versus narcissism. Alternative Proposal: Diagnostic Trait Facets for the Narcissistic Personality Disorder Type Traits 1. or covertly in persistent convictions and fantasies of unfulfilled ambitions or unlimited success.e. internally self-sufficient or interpersonally controlling. distant. 2009. reactivity. uniqueness. or competitive. and social advantage of others (exploitive). brilliance. excessive attention or admiration seeking. While the overlap between HPD and NPD has been acknowledged (Morey & Jones. harsh self-criticism.. powerlessness. aggressive. Self-serving interpersonal behavior—i. or elation). or uncommitted attitude or behavior that serves to avoid threats to self-esteem or intolerable affects. or taking emotional. expecting unreasonable and unwarranted rights and services. a central part of self-regulation. is less focused on symptomatic features or phenotypic appearance. 4. anxiety. attitude or behavior. defeats. 2.e. and self-centeredness. and includes basic characteristics of narcissistic functioning that can distinguish temporary. Histrionic seductive exhibitionism is different from narcissistically driven self-enhancing. superiority and assertiveness. anger). depression. Variable self esteem—alternating between states of overconfidence.. power. or shame). . often competitive. shame or deceitfulness when self or others fail to measure up. shame. envy. value. Regulation of self-esteem.e. NPD type and traits­ —AN Alternative proposal A diagnostic approach is needed that identifies basic indicators for the range of narcissistic personality functioning. beauty. or externally-triggered shifts in function and appearance from enduring indications of pathological narcissism.

Grandiosity is also manifested by exceptionally high ideals and perfectionism. If expectations are not met. or taking emotional. harsh self-criticism. Self-enhancing and self-promoting interpersonal behavior can serve to boost or protect the self-esteem. others tend to exercise rigorous in- . shame). self-serving. or covertly in inner convictions. They can also show vigorous self-serving interpersonal behavior—i. A broader definition of grandiosity is necessary that captures not only a sense of superiority and fantasies. They present with grandiosity. Vulnerability is evident by exaggerated reactivity. While some readily express their reactions. as well as the sustaining self-enhancing and self-serving interpersonal behavior. envy. In addition. defeats. power. mood variations (irritability. These individuals react strongly to perceived challenges or threats to self-esteem (i. an enhanced or unrealistic sense of superiority. the most significant trait of NPD (compare: vulnerability and reactions to abandonment as a central marker for borderline personality disorder). exploitiveness. and aggressive behavior. i. self-promoting. Variability is evident by states ranging from overconfidence. rage.RETAINING A SIGNIFICANT DIAGNOSIS 255 the self-esteem. avoidance or retaliating or deceitful behavior. They also have variable or consistently impaired empathic ability. superiority and assertiveness to inferiority and insecurity. but also includes perfectionism and high ideals. controlling. with self-enhancing interpersonal behavior­ —i. and competitive.e. value or capability. criticism and failure to measure up).e. exceptionally high aspirations. influenced by emotional dysregulation (low affect tolerance or intense reactions) and/or self-centeredness or self-serving interests. accepting unreciprocated favors from others. depression or elation). they aim at introducing a more dynamic and treatment-guiding conceptualization of the narcissistic traits. They also serve to capture its fluctuations. to shame and severe self-criticism.. brilliance. expecting unreasonable and unwarranted rights and services. anxiety. This is expressed either overtly in unwarranted expectations. intellectual and social advantage of others. uniqueness. and self-centeredness. These reformulations serve to expand the spectrum of grandiosity-promoting strivings and activities.. and attend to the narcissistic individual’s internal experiences and motivation as well as his or her external presentation with interpersonal self-enhancing.. such as self-enhancing and self-serving instead of the traditional narcissistic triple E: entitlement. with overt or covert intense feelings (anger. beauty.e. hostility. fantasies of unfulfilled ambitions or unlimited success. they tend to have intense reactions ranging from rage and retaliation to passive-aggressive rumination. Individuals with the narcissistic personality type can present as overtly arrogant and haughty. I suggest the following description of the Narcissistic Personality Disorder Type to be included in DSM-5: “Individuals with this personality type suffer from variable and vulnerable self-esteem. humiliation. being actively attention and admiration seeking. or ideal relationships..e. boastful. and exhibitionism.

or avoidant. criminal or psychopathic behavior can also be present. indicative of relevant underlying context and meaning of the diagnostic traits and descriptive personality functioning.256 RONNINGSTAM ternal control over their emotions. and indifferent. social and societal significance especially when associated to functional vocational and interpersonal impairment. controlled and polite. A third presentation includes those who are more manifestly aggressive and hostile. vengefulness or sadism. They also suffer from internal vulnerability. However. its psychiatric. hiding or feigning disinterest in self-promotion. and acute suicidality. their avoidance serves to sustain elevated self-esteem and they are still preoccupied with self-enhancing grandiose fantasies and passive aggressive reactions. or interpersonal relationships. In addition. they demonstrate systematic cruel. sadistic or violent interpersonal behavior. deceptive and seductive. social and moral adaptation. Those with a covert presentation have a more shy appearance and can be self-sufficient. and guiding of relevant treatment approaches. there is a need for an established and well-defined diagnostic base for continuing studies of treatment of narcissism and NPD.” Recommendations to the DSM V Committee 1. Promote an informative and guiding conceptualization of NPD The NPD diagnosis must be clinically and psycho-educationally informative for both clinicians and patients. Some are charming. exploitive and retaliating. others are calculating. Motivated by superiority. envy. and that are less contingent upon situational changeability and range of phenotypic variability. modest. or unassuming. inferiority and shame. Retain NPD as a diagnostic personality disorder type There is by now strong supporting evidence in favor of keeping NPD as a personality type with a set of separate diagnostic criteria in DSM V. empty. Include traits that capture basic enduring indicators of NPD To enhance the relevance and utility of the NPD diagnosis it has to capture basic characteristics of narcissistic functioning that represent enduring indication as well as core features for narcissistic personality functioning. These include: the prevalence rate. insecurity. 2. . 3. expressed behavior. extensive clinical and empirical reports and facts. Malignant. On the surface they can appear tuned in.

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