DSM-5: T 05 Narcissistic Personality Disorder

[CZBZ]

American Psychiatric Association
DSM-5 Development
Updated June 21, 2011

T 05 Narcissistic 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 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).

(This is a copy of the APA's DSM-5 Development Page)

[CZBZ]

This is a very informative PDF article by the American Psychiatric Association. It describes the differences between the DSM-IV criteria for the Narcissistic Personality Disorder (NPD), DSM-5 criteria, and DSM-5 revised criteria June 2011.

[alatariel]

I have a question about this

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).

How do "they" determine if an impairment is due to the direct physiological effects of a substance, when the person is a substance abuser? 

I can see how it can be due to the effects of a drug in general, b/c I took a prescription drug for a short time that made me aggressive and mean, like having constant PMS anger.  Which was noticeable, b/c I'm NOT ever, at all, an aggressive person.  But when someone is a chronic drug user, and has been for their entire adult life, how do you separate the effect of the drug from their general personality?

I ask b/c I have to wonder about dickhead.  He is an alcoholic, and that's dx'd by a professional, not just me.  He was also dx'd with "social anxiety disorder" by the professionals.  I believe he's a covert narcissist, and probably actually HAS NPD.  Is it directly attributable to the effect of alcohol?  Well, as far as I knew, he wasn't drinking for a few years, and he was still the same bazturd he'd always been, just one who could walk in a straight line.  But how would anyone ever know?  You'd have to separate him from his alcohol for years for him to fully recover from the effects of his addiction...

[Chime]

I also hesitate at the "socio-cultural environment"
 
is that ever a grey area - oh, it's ok 'cause you're ___________ (fill in the blank)
working on wall street? hispanic?  african?  french?  poor?  that's what they do where you come from?  WHAT?!

Chime

[alatariel]

Good one.  Maybe they use it to excuse a MLC, b/c that's "normal" behavior for our culture?  Or to excuse teenage selfishness, b/c our culture encourages and demands that teens be self-centered?

[Chime]

Eggsactly!!!


Chime

[CZBZ]

My understanding is that psychologists treat the alcoholism first, or encourage clients to stop abusing drugs before treatment. So, if someone is alcoholic, it would be noted on their diagnosis and taken into consideration. The alcoholism would be part of the whole picture. But they might also receive a co-morbid diagnosis of NPD and alcoholism depending on the client's long-term "impairments." How far back did they exhibit narcissistic behaviors?

 I find it interesting how psychologists have created a system that allows them to pinpoint someone's problems. Because like you've been saying on this thread, there are so many issues going on with that person, where does one even start? A narcissist is kinda like a ball of string...you can't even find the 'end' to unwind the mess. When I saw how the DSM was based on a multi-axial system for categorizing information, well, I thought it was damn impressive! It even takes into consideration, the client's situation; such as divorce, poverty, mourning, etc. which definitely affects our state of being.

I have described how the DSM categorizes a client's mental health on a link at the top left-side of our page: The DSM, Axis II, Cluster B. For a better example of DSM codes, this article was interesting: DSM-IV codes on PsychCentral

As far as the impact of socio-cultural environment goes, this is how I've sorted that through: My extremely religious upbringing and my 'age' group bears weight with my beliefs-and-assumptions about marriage, family, women's roles and men. A woman born twenty years later than myself, has a different set of cultural beliefs about herself, marriage, men and family. And so the story goes. The way I organized life according to my socio-cultural environment might be considered "unhealthy"  for my younger nieces who did not experience the same gender restrictions (they have their own 'fun' set of trubbles to work through, tho).

I encountered this issue with a dear friend of mine who was Japanese. When her little daughter went to kindergarten, the teacher was alarmed at her 'shyness' and suggested the family get counseling. This was a misunderstanding on the teacher's part, of the socio-cultural environment of Japanese families who aren't pleased when a child "stands out" or draws attention to herself (what Americans consider to be charming and healthy). If my friend had gone to a psychologist (which she didn't), it's good to know that her cultural norms would not be pathologized by an American psychologist.

Just a few thoughts on that.

Hugs,
CZ