Narcissistic Pathology as Core Personality Dysfunction: Comparing the DSM‐IV and the DSM‐5 Proposal for Narcissistic Personality Disorder

Abstract

Narcissistic personality disorder and related concepts have a complex history and have been subject to extensive theoretical discourse but relatively little empirical research. An initial proposal for the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) that suggested eliminating this disorder as a discrete personality disorder type met with considerable controversy that ultimately led to its reinstatement in subsequent proposals. Nonetheless, the DSM-5 proposal for personality disorders as a whole would involve a significantly different formulation of narcissistic personality from that described in DSM-IV-one that places a greater emphasis on shared deficits among all personality disorders that tap elements thought to fall on the narcissistic spectrum, such as deficits in empathic capacity. This article describes this revised formulation, and presents a case study that illustrates the similarities and differences in the DSM-IV and proposed DSM-5 portrayal of narcissistic issues and related clinical problems over the course of a particular treatment.

Are malignant self‐regard and vulnerable narcissism different constructs?

“…For instance, Morey () reported that empathic failure was prominent component of all PDs and was part of their overall impairment in functioning. And, Morey and Stegner () described how Freud's (/1957) original writing on narcissism did not describe it as a categorical disorder, but rather the outcome of a dysfunctional developmental process in learning how to develop interpersonal relationships that were healthy and life‐supporting.…”

Looking ahead through a fragile lens: Vulnerable narcissism and the future self

“…Variations on the latter perspective include the notion that vulnerable narcissism may represent the failure of self‐enhancement efforts, or an underlying sensitivity to shame that prompts the deployment of grandiose self‐regulatory mechanisms . It has also been suggested, however, that vulnerable narcissism may represent a core aspect of general personality dysfunction, centred around persistent feelings of inadequacy and interpersonal hypersensitivity rooted in distorted self‐other representations – thus potentially cutting across various categories of personality disorder …”

Interpersonal problems associated with narcissism among psychiatric outpatients: A replication study .

“…Some studies have shown NPD to suffer from low discriminant validity, sharing common traits with other personality disorders and thus contributing to high rates of comorbidity within the personality disorder class [4,7,8], though this is a problem that is hardly specific to NPD alone. Without research clearly supporting the DSM-IV operationalization of NPD (or a valid alternative), the DSM-5 working group's proposal was to remove NPD from the DSM-5 [9].…”

“…The scientific literature on NPD includes discussion of the scarcity of evidence supporting its validity [3,4]. Links et al [5] conclude, "Most of the literature regarding patients suffering with narcissistic personality disorder is based on clinical experience and theoretical formulations, rather than empirical evidence" (p. 303).…”

“…Links et al [5] conclude, "Most of the literature regarding patients suffering with narcissistic personality disorder is based on clinical experience and theoretical formulations, rather than empirical evidence" (p. 303). At the time of the DSM-5 working group discussions to consider changes to the personality disorder construct and diagnosis, only 4% of the 15,000 scientific articles on DSM-IV personality disorders focused on NPD [4]. This is in contrast to escalating prevalence rates for NPD, with a recent epidemiological study [6] finding a 6.2% lifetime prevalence in the general population and an even higher prevalence of 9.4% in younger cohorts (20)(21)(22)(23)(24)(25)(26)(27)(28)(29) …”