DSM-IV SourcebookNarcissistic Personality Disorder
John Gunderson, M.D., Elsa Ronningstam, Ph.D., and Lauren E. Smith, B.A.
Narcissistic personality disorder (NPD) was introduced into our diagnostic system in DSM-III (American Psychiatric Association 1980). There was no precedent in earlier DSMs or in the ICD for a narcissistic category. The stimulus for its inclusion derived from the widespread use of the term by psychodynamically informed clinicians. The DSM-III definition of NPD arose out of that committee’s summary of the pre-1978 literature and was modified for DSM-III-R (American Psychiatric Association 1987) after additional expert input.
Notable in the changes that occurred from DSM-III to DSM-III-R were the following:
1. The format for the criteria were changed from a mixed polythetic-monothertic criteria set to a polythetic set.
2. DSM-III included interpersonal relationship features as one criteria with the requirement that patients have two of the four listed options. In DSM-III-R, these four options were made into three separate criteria; namely, criterion 2 (exploitative), criterion 6 (entitlement), and criterion 8 (lack of empathy). The fourth option in DSM-III, “relationships characterized by idealization and devaluation,” was dropped in DSM-III-R because it overlapped with a similar criterion for borderline personality disorder (BPD).
3. Criterion 3 in DSM-III related to both grandiosity and uniqueness. It was subdivided into two criteria in DSM-III-R: criterion 3 retained the focus on grandiosity per se, and a second criter
4. A new criterion (criterion 9) concerning preoccupation with feelings of envy was added in DSM-III-R.
DSM-III-R criteria for narcissistic personality disorder and proposed changes for DSM-IV
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration (HYPERSENSITIVITY TO THE EVALUATION OF OTHERS), and a lack of empathy beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following:
1. has grandiose sense of self-important (e.g., exaggerates achievements and talents, expects to be
recognized as superior without commensurate achievements [NOTICED AS “SPECIAL” WITHOUT APPROPRIATE ACHIEVEMENT] (DSM-III-R criterion 3)
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love (DSM-III-R criterion 5)
3. believes that [HIS OR HER PROBLEMS ARE UNIQUE]
he or she is “special” and unique and can be understood only by,
or should be associated with, other special or
high-status people
(or institutions) (DSM-III-R criterion 4)
4. requires [CONSTANT]
excessive admiration [AND ATTENTION, E.G., KEEPS FISHING FOR COMPLIMENTS] (DSM-III-R criterion 7)
5. has a sense of entitlement: unreasonable expectations of especially favorable treatment or
automatic compliance with his or her expectations [E.G., ASSUMES THAT HE OR SHE DOES NOT HAVE TO WAIT IN LINE WHEN OTHERS MUST DO SO] (DSM-III-R criterion 6)
6. is interpersonally exploitative: takes advantage of others to achieve his or her own ends (DSM-III-R criterion 2)
7. lack of empathy: inability to recognize [AND EXPERIENCE HOW OTHERS FEEL]
or identify with the feelings
and needs of others [E.G., ANNOYANCE AND SURPRISE WHEN A FRIEND WHO IS SERIOUSLY ILL CANCELS A DATE] (DSM-III-R criterion 8)
8. is [PREOCCUPIED WITH FEELINGS OF ENVY]
often envious of others or believes that others are envious of him or her (e.g., often resents others who have privileges, achievements, or loyalties that they feel are better deserved by themselves.) 9.
arrogant, haughty behaviors or attitudes (new criterion proposed for DSM-IV) [REACTS TO CRITICISM WITH FEELINGS OF RAGE, SHAME, OR HUMILIATION (EVEN IF NOT EXPRESSED)] (DSM-III-R criterion 1)
note: contents of DSM-III-R whose omission is proposed are [CAPITALIZED AND BRACKETED]. Contents that are proposed for addition in DSM-IV are printed
in bold type. Criteria appear in the order proposed for DSM-IV.
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