Background

Covert, Women Narcissists Make It Into NEW DSM 5-TR

Uploaded 7/17/2022, approx. 39 minute read

Good morning, Svanpanim. I have several earth-shattering news for you. Number one, Minnie, my black smiling borderline is back. You can see on my face that my anxiety is much mitigated and relieved, and I'm not asking her where she has been. Don't ask, don't tell.

Second bit of news, taking into account your level of IQ and illiteracy, I am not going to use words like very similitude, alacrity, and so on. I'm going to go easy on you this time.

And the tinting alarmin of your supplication had reached my ears and I relented. Look it up.


Today we are going to discuss the much awaited new edition of the Diagnostic and Statistical Manual AKA DSM. It is a DSM-5 and it is the text revision released a few weeks ago, nine years in the making.

And there are two breaking news when it comes to narcissistic personality disorder. For the first time, the manual acknowledges the existence of covert or vulnerable narcissists, explicitly in the text, as you will see.

The second, in my view, equally important piece of news is that the DSM accepts parity between women and men. Women and men presenting in clinical settings are equally as likely to be diagnosed with narcissistic personality disorder. And that is a major shift since the 1980s and 90s when the third and fourth editions of the DSM were published.

And yet, having ploughed through this fixed tome, 1,100 pages, 10 times as long as the first edition in 1952, by the way, having ploughed through it, I am disappointed. I'm disappointed and I think the Diagnostic and Statistical Manual Committee is still to some extent in hoc to the insurance industry and the interests of the pharmaceutical industry. I'm sorry to say. And I refer you to my video where I compare the DSM to the 11th edition of the ICD, International Classification of Diseases, published by the World Health Organization. The ICD is the world's DSM. DSM is used mostly in North America. The ICD is courageous. It has gone where no one has before. And it incorporates the latest cutting edge, bleeding edge info emanating from academe. I can't say this about the DSM. I wish I could.

There are hesitant, pusillanimous attempts in the DSM, in the current text revision, to kind of experiment with and broach the possibility of a dimensional model without a list of diagnostic criteria. And I will analyze these attempts shortly. But they fall short. All in all, they fall short.

And indeed, the American Psychiatric Association, the publisher of the Diagnostic and Statistical Manual, described the text revision as a facelift. They admitted.

Anyhow, I'm going to read extensive excerpts from the text revision and dwell upon the changes to the diagnostic criteria and so on and so forth.

When it comes to cluster B personality disorders, there are some things which are very new. And there is an incorporation of the latest research and the latest knowledge. So I'm going to make a series of videos. Each one, each video dedicated to another cluster B personality disorder.

The first one, of course, is narcissistic personality disorder. The next video I will make is borderline personality disorder in the DSM-5 text revision, etc.

And then psychopathy, antisocial personality disorder, and so on. So what does the American Psychiatric Association have to say about the latest attempt at capturing the psychopathology of the human soul? What does it say about the current state of knowledge, state of art, when it comes to clinical psychology?

And I'll be quoting from now, from here on, I'll be quoting.

I'll be citing the text.

They say, mental disorders, fifth edition text revision, DSM-5-TR, is the first published revision of the DSM-5. This revised manual integrates the original published DSM diagnostic criteria with modifications, mostly for clarity, for over 70 disorders.

A comprehensively updated descriptive text accompanying each of the DSM disorders based on reviews of the literature since the publication of the DSM-5 and the addition of a new diagnosis, prolonged grief disorder.

Yes, you've heard it. You've heard it here for the first time.

Richard and I discussed prolonged grief disorder way before it had become an official diagnosis in the text revision of the DSM-5.

Okay.

And then there are symptom codes for reporting suicidal and non-suicidal self-injurious behavior.

The APA continues to say, these changes differ from the scope of the prior text revision, DSM-4 text revision, in which the updates were confined almost exclusively to the text, leaving the diagnostic criteria virtually unchanged.

This addition also integrates all prior online updates made to the DSM-5 after its publication in 2013 in response to usage, specific scientific advances, and ICD-10-CM coding adjustments through an iterative revision process.

Consequently, says the American Psychiatric Association, the publisher of the DSM, consequently, the DSM-5-TR is a product of three separate revision processes, each one overseen by separate but overlapping groups of experts.

The development of the original DSM-5 diagnostic criteria and text by the DSM-5 task force published in 2013. Updates to the DSM-5 diagnostic criteria and text by the DSM steering committee, which has overseen the iterative revision process and fully updated text overseen by the revision subcommittee.

Talk about bureaucracy. The clinical and research understanding of mental disorders continues to advance, no kidding.

As a result, most of the DSM-5-TR disorder texts have had at least some revision since the nine years from original publication in DSM-5, with the overwhelming majority having had significant revisions.

I couldn't say this, by the way, in the cluster B personality disorders, but what do I know?

APA continues. Sections of the text that were most extensively updated were prevalence, risk, and prognostic factors, culture-related diagnostic issues, sex and gender-related diagnostic issues, association with suicidal thoughts or behavior, and comorbidity.

Also, for the first time ever, the entire DSM text has been reviewed and revised by a work group on ethnoracial equality and inclusion to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as to the use of non-stigmatizing language.

The White Movement had reached the DSM.

Congratulations.

And here is what the DSM, the new version, the text revision, has to say in capsule, in a nutshell, about the cluster B personality disorders.

Antisocial personality disorder, says the DSM-TR, is a pattern of disregard for and violation of the rights of others, impulsivity and a failure to learn from experience.

That's my autobiography in short form.

Borderline personality disorder is a pattern of instability in interpersonal relationships, self-image and effects, and marked impulsivity.

Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.

It is regrettable that the DSM-5 didn't merge histrionic personality disorder with either borderline personality disorder or with antisocial personality disorder, especially the malignant forms known as psychopathy.

This is the latest thinking.

And finally, the DSM-TR defines narcissistic personality disorder as a pattern of grandiosity, need for admiration, and lack of empathy.

What does the text revision have to say about cluster B in general?

It says cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders.

I remind you, by the way, that cluster B is also known as erratic and dramatic or dramatic personality disorder.

The DSM continues, individuals with these cluster B disorders often appear dramatic, emotional, or erratic.

A review of epidemiological studies from several countries found a median prevalence of 3.6% for disorders in cluster A, 4.5% for cluster B, 2.8% for cluster C, and 10.5% for any personality disorder.

Prevalence appears to vary across countries and by ethnicity, raising questions about true cross-cultural variation and about the impact of diverse definitions and diagnostic instruments on prevalence assessments.

I would even add and say that such variants among cultures may raise the possibility that these are not real clinical entities at all, but culture-balanced syndromes.

But that's a debate for another time.


And the DSM-5 introduces dimensional models for personality disorders.

It explains these models in the following way.

The diagnostic approach used in this manual represents the categorical perspective that personality disorders are qualitatively distinct clinical syndromes.

An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another.

By the way, I've been advocating this since 1995. And so they created in the text revision, actually in the DSM-5, they created a whole section dedicated to this alternative dimensional model.

Section three, and there's a full description of the dimensional model for personality disorders in that section.

The DSM continues to say, the DSM-5 personality disorder clusters, odd, eccentric, dramatic, emotional, and anxious, fearful, may also be viewed as dimensions representing spectra of personality dysfunction on a continuum with other mental disorders.

Yes, exactly, DSM.

The alternative dimensional models have much in common and together appear to cover the important areas of personality dysfunction.


Here's to many.

Their integration, clinical utility, and relationship with the personality disorder diagnostic categories and various aspects of personality dysfunction continue to be under active investigation.

They need to establish the validity of these alternative models.

This includes research on whether the dimensional model can clarify the cross-cultural prevalence variations seen with a categorical model.

Okay, let's get to business.

And our business, of course, is cluster B personality disorders.

In this video, I'm going to cover narcissistic personality disorder.

The survivors of this video can proceed in the future to other videos in which I will cover borderline personality disorder and antisocial personality disorder, as well as psychopathy.

Okay, let's start with narcissistic personality disorder in a few breaking news.

Prevalence. I'm reading from the text. The estimated prevalence of narcissistic personality disorder based on a probability sub-sample from part two of the national comorbidity survey replication and the national epidemiologic survey on alcohol and related conditions.

So this prevalence was actually 6.2%.

Yes, all of you were right. Narcissism is far more widespread than was given credit for in previous editions of the DSM.

A review of five epidemiological studies for in the United States found a median prevalence of 1.6%.

So there is still a big debate as to how prevalent narcissism is. But taking into account, for example, the fact that narcissists are reluctant to attend therapy or to be diagnosed, I think the 6% is closer to the mark, between three and five definitely.

What about sex and gender related features?

The DSM has this to say.

Among adults aged 18 and older diagnosed with narcissistic personality disorder, 50 to 75% are men.

So for the first time or for the second time, actually, the DSM accepts that about 50% of all people diagnosed with NPD are actually women.

This is a major explosion in the diagnosis of narcissism, pathological narcissism among women.

Gender differences, the text continues, gender differences in adults with this disorder include stronger reactivity in response to stress and compromised empathic processing in men, as opposed to self-focus and withdrawal in women.

As I've been saying, women and men manifest, express narcissistic personality disorder differently. Culturally based gender patterns, says the DSM, and expectations may also contribute to gender differences in narcissistic personality disorder, traits and patterns.

So gender bias and even misogyny are reflected in the work on narcissistic personality disorder over the decades, starting 107 years ago.

What happened to the diagnostic criteria?

In short, nothing since the DSM edition three text revision, we're talking 40 plus years, something is wrong with that.

We know a lot more about narcissistic personality disorder than we had known in 1980. And yet the text has the text of the diagnostic criteria has changed very little, if at all.

This doesn't sound right, but at any rate, I'm going to read the text to you.

Diagnostic criteria, F60.81.

A pervasive pattern of grandiosity in fantasy or behavior, need for admiration and lack of empathy, beginning by early adulthood, presented and present in a variety of contexts, as indicated by five or more of the following diagnostic criteria.

Number one is a grandiose sense of self importance.

Example exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements.

Number two is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

Number three, ideal love, by the way, is what I call in what Sanger called shared fantasy.

Number three believes that he or she is special and unique, and can only be understood by or should associate with other special or high status people or institutions.

Number four requires excessive admiration.

Number five, bring it on, bring it on.

Number five has a sense of entitlement.

In other words, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.

Number six is interpersonally exploitative, takes advantage of others to achieve his or her own ends.

Number seven lacks empathy, is unwilling to recognize or identify with the feelings and needs of others.

Number eight is often envious of others or believes that others are envious of him or her.

Number nine shows arrogant, haughty behaviors or attitudes.

By the way, those of you who want to view, want to actually read these criteria, it's on page 760.

Much more important than the diagnostic criteria to my mind is the text.

Now the text which describes the narcissist, his functioning, his interpersonal relationshipsand his internal landscape, the text had been revised, had been revised in each and every edition of the DSM, and the text revision of DSM-5 is no exception.

There are few revisions to the text. Rather than point out the differences, I'm going to simply read the entire text to you because it's an excellent introduction to the narcissist, to pathological narcissism, and a counterweight to many nonsensical self-styled experts with and without academic degrees.

Listen well, this is the Bible of the psychiatric profession. Ignore most of the trash online.

Here's what the DSM text revision has to say about narcissistic personality disorder, starting with its diagnostic features.

The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood, by early adulthood, not earlier, and present in a variety of contexts.

Individuals with this disorder have a grandiose sense of self-importance, which may be manifest as an exaggerated or unrealistic sense of superiority, value, or capability. They tend to overestimate their abilities and amplify their accomplishments, often appearing boastful and pretentious.

Yes, yes, I hear you. They may blithely assume that others attribute the same value to their efforts and may be surprised when the praise they expect and feel they deserve is not forthcoming.

Often implicit in the inflated judgments of their own accomplishments is an underestimation or devaluation of the contributions of other people.

Individuals with narcissistic personality disorder are often preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. They may ruminate about long overdue admiration and privilege and compare themselves favorably with famous or privileged people.

Now, before I proceed, the alternative model, which I will read to you later, modifies this and it modifies this to incorporate the latest research which demonstrates conclusively that all this is a facade. It's a compensatory effort. The narcissist deep inside feels inferior, feels empty, feels inadequate, and he tries to compensate for this by pretending to be exactly the opposite.

But this does not appear in edition four and the text revision of edition four. It makes an appearance for the first time subtly in the DSM-5 and openly and explicitly in this text revision.

So the alternative model is very important, much more important than the classical 40 years old diagnostic criterion. And still, I'm going to present to you the entire text so that you can form your own opinions and make up your own minds.

Individuals, the text continues, individuals with narcissistic personality disorder believe that they are special or unique and expect others to recognize them as such. They can be surprised or even devastated when the recognition of a claim that they expect and feel that they deserve from others is not forthcoming.

They may feel that they can only be understood by and should only associate with people of high status and may attribute unique, perfect, or gifted qualities to those with whom they associate.

This is the process of co-idealization. Individuals with this disorder believe that their needs are special and beyond the canon of ordinary people. Their own self-esteem is enhanced, mirrored by the idealized value that they assign to those with whom they associate co-idealization.

They are likely to insist on having only the top person, doctor, lawyer, hairdresser, instructor, or they would insist on being affiliated with the best institutions, but they may devalue the credentials of those who disappoint them.

Individuals with this disorder generally require excessive admiration. Their self-esteem is almost invariably very fragile, and their struggle with severe internal self-doubt, self-criticism, and emptiness results in their need to actively seek others' admiration.

Here we come to the compensatory aspect of narcissism. This is why we are beginning to think that narcissists who are egotistonic, narcissists who don't feel inferior, narcissists who don't feel inadequate are actually not narcissists at all, but psychopaths.

What we used to call the overt grandiose narcissist is probably a subspecies or subvariant of a psychopath, and the only real narcissist is the overt or grandiose narcissist who is compensatory, compensates for a lack of inner conviction, for a very harsh inner critic, for unrelenting self-criticism.

This would be a true narcissist or a covert narcissist. That's another variant of a true narcissist.

The text continues, narcissists may be preoccupied with how well they're doing and how favorably they are regarded by others. They may expect their arrival to be greeted with great fanfare, and they are astonished if others do not covet their positions. They may constantly fish for compliments, often with great charm.

This is something I call false modesty.

The narcissist continues the text. The narcissist has a sense of entitlement which is rooted in their distorted sense of self-worth, and it is evident in these individuals' unreasonable expectation of especially favorable treatment. They expect to be catered to and are puzzled or furious when this does not happen.

For example, they may assume that they do not have to wait in line and that their priorities are so important that others should defer to them and then get irritated when others fail to assist in their very important work.

They expect to be given whatever they want or feel they need, no matter what it might mean to others. For example, these individuals may expect great dedication from others, may overwork others without regard for the impact on other people's lives.

This sense of entitlement, combined with a lack of understanding and sensitivity to the wants and needs of others, may result in the conscious, unwitting exploitation of other people.

Narcissists tend to form friendships or romantic relationships only if the other person seems likely to advance their purposes or otherwise enhance their self-esteem, source of narcissistic supply.

They often usurp special privileges and extra resources that they believe they deserve.

Some individuals with Narcissistic Personality Disorder intentionally and purposefully take advantage of others emotionally, socially, intellectually or financially for their own purposes and gains.

This would be the psychopathic end of the spectrum, by the way. This would be the psychopathic or malignant narcissist.

Continuing the text, individuals with Narcissistic Personality Disorder generally have a lack of empathy and are unwilling to recognize or identify with the desires, subjective experiences and feelings of other people. They tend to have some degree of cognitive empathy. That's what I call cold empathy. Cognitive empathy is one component of cold empathy. Cold empathy is reflexive empathy plus cognitive empathy.


So, coming back to the text, narcissists tend to have some degree of cognitive empathy. That's a major departure from previous DSM editions, by the way.

Some degree of cognitive empathy, understanding another person's perspective on an intellectual level.

But narcissists lack emotional empathy, directly feeling the emotions that another person is feeling.

These individuals may be oblivious to the hurt their remarks may inflict. For example, exuberantly telling a former lover that I'm now in the relationship of a lifetime or boasting of health in front of someone who is terminally ill.

When recognized, the needs, desires or feelings of other people are likely to be viewed disparagingly, signs of weakness or vulnerability.

Those who relate to individuals with Narcissistic Personality Disorder typically find an emotional coldness and lack of reciprocal interest.

These individuals are often envious of others or believe that others are envious of them. They may begrudge others their successes or possessions, feeling that they better deserve those achievements, admiration or privileges. They may harshly devalue the contributions of other people, particularly when those individuals have received acknowledgement or praise for their accomplishments.

Arrogant, haughty behaviors, characterized narcissists, they often display snobbish, disdainful or patronizing attitudes. These are the diagnostic features.


What about the clinical picture, what we call the associated features?

The text says, vulnerability in self-esteem makes individuals with Narcissistic Personality Disorder very sensitive to criticism or defeat. Although they may not show it outwardly, such experiences may leave them feeling ashamed, humiliated, degraded, hollow and empty. They may react with disdain, rage or counter-attack, however, such experiences can also lead to social withdrawal or an appearance of humility that may mask and protect the grandiosity.

I've described this in my writings decades ago, how narcissists become schizoid, how they withdraw when they are narcissistically injured, let alone mortified. I also describe false modesty or pseudo humility.


Interpersonal relations continue, they are typically impaired because of problems related to self-preoccupation, entitlement, need for admiration and relative disregard for the sensitivities of others.

Individuals with Narcissistic Personality Disorder can be competent and high-functioning with professional and social success, while others can have various levels of functional impairment.

So we have high-functioning narcissism, low-functioning narcissism. Professional capability combined with self-control, stoicism and interpersonal distancing with minimal self-disclosure can support sustained life engagement and even enable marriage and social affiliations.

Sometimes ambition and temporary confidence lead to high achievements, but performance can be disrupted because of fluctuating self-confidence and intolerance of criticism or defeat.

Do you hear this Donald Trump? Some individuals with Narcissistic Personality Disorder have very low vocational functioning, reflecting an unwillingness to take a risk in competitive or other situations in which failure or defeat can be possible.

Narcissists also, may I add, lazy and some of them are perfectionists which causes them to procrastinate or avoid tasks altogether. That's my my vision.

Back to the text. Low self-esteem with inferiority, vulnerability and sustained feelings of shame, envy and humiliation accompanied by self-criticism and insecurity can make individuals with Narcissistic Personality Disorder susceptible to social withdrawal, emptiness and depressed mood.


Finally, there's a revolutionary part and reflects everything I've been saying in this channel for almost 15 years.

High perfectionist standards are often associated with significant fear of exposure to imperfection, failure and overwhelming emotions.

What does a DSM 5 text revision have to say about the development of Narcissistic Personality Disorder in the course of the disorder, the trajectory?

Here too, the text has been revised to reflect current knowledge. Narcissistic traits, says the text, may be particularly common in adolescents, but do not necessarily indicate that the individual will develop Narcissistic Personality Disorder in adulthood.

Yes, I've been saying it for many, many years. Adolescents are narcissists. People, infants at age 2 are narcissists.

Healthy narcissism is crucial to separation, individuation and identity formation.

The DSM continues, predominant Narcissistic traits or manifestations of the full disorder may first come to clinical attention or be exacerbated in the context of unexpected or extremely challenging life experiences or crises, what I call hitting rock bottom.

What kind of crises, bankruptcies, demotions, loss of work or divorces, suggests the DSM.

In addition, says the DSM, individuals with Narcissistic Personality Disorder may have specific difficulties adjusting to the onset of physical and occupational limitations that are inherent in the aging process.

Tell me about it.

However, life experiences such as new, durable relationships, real, successful achievements and tolerable disappointments and setbacks can all be corrective and contribute to changes and improvements in individuals with this disorder.


So what about the debate? There's a debate. Are narcissists only bad? Is this a societal verdict? Does the diagnostic category of Narcissistic Personality Disorder reflect social mores and therefore is not a clinical entity or is it real?

So this is what the DSM has to say, cultural related diagnostic issues.

Narcissistic traits may be elevated in socio-cultural contexts that emphasize individualism and personal autonomy over collectivist goals.

Compared with collectivist contexts, in individualistic contexts, narcissistic traits may warrant less clinical attention or less frequently lead to social impairment.

Here I disagree with the DSM and I've been disagreeing with the DSM for decades.

The locus of grandiosity can be individualistic but can also be also collectivist.

If you talk to a Japanese narcissist, he is not likely to brag of his own traits, accomplishments and behaviors, but he is likely to boast of the traits, accomplishments and behaviors of the company he works for or of his nation or of his family.

The locus of grandiosity shifts from the individual to the collective but it is still pathological.


What about suicide? Is it common?

The DSM has this to say about association with suicidal thoughts or behavior.

In the context of severe stress and given the perfectionism often associated with Narcissistic Personality Disorder, exposure to imperfection, failure and overwhelming emotions can evoke suicidal ideation.

They are referring actually to narcissistic modification.

Suicide attempts in individuals with Narcissistic Personality Disorder tend to be less impulsive and are characterized by higher lethality compared with suicide attempts by individuals with other personality disorders.

In other words, the narcissist plans and then executes the suicide and he's hell-bent and intent on accomplishing this goal.

While the borderline, for example, uses suicide threats as a cry for help and attempts to attract attention and many of her attempted suicides fail.

But it's very crucial to note that 11 percent of people diagnosed with Borderline Personality Disorder end their lives successfully and that this figure is dramatically higher than among people with Narcissistic Personality Disorder.

Differential diagnosis.

How can we tell narcissism from other personality disorders, especially other personality disorders in cluster B?

Other personality disorders, says the DSM, may be confused with Narcissistic Personality Disorder.

Do you hear that? All you self-styled experts online with and without academic degrees, you're making a hash of it. You're misleading your audience, conflating and confusing Narcissistic Personality Disorder with anti-social personality disorder, psychopathy and so on.

So the DSM harshly criticizes you indirectly.

I repeat, other personality disorders, says the DSM, may be confused with Narcissistic Personality Disorder because they have certain features in common.

For example, grandiosity, although grandiosity is common to psychopathy, narcissism and borderline, but not all psychopaths are narcissists.

If you say that all psychopaths are narcissists, you have no idea. You don't have the first inkling about narcissism or psychopathy.

You're not an expert, you're a con artist.

It is therefore important to distinguish among these disorders based on differences in their characteristic features.

Admonishes the DSM.

However, if an individual has personality features that meet criteria for one or more personality disorders, in addition to Narcissistic Personality Disorder, all of these disorders can be diagnosed and this is called comorbidity.

The most useful feature in discriminating Narcissistic Personality Disorder from histrionic, anti-social and borderline personality disorders in which interactive styles are coquettish, callous and needy respectively is the grandiosity characteristic of Narcissistic Personality Disorder.

The relative stability of self-image and self-control, as well as a relative lack of self-destructiveness, impulsivity, separation insecurity and emotional hyper-reactivity also help distinguish Narcissistic Personality Disorder from borderline personality disorder.

I will try to decipher this passage for you because it's very crucial.

They say that narcissists have a stable self-image. Their grandiosity is there all the time and that's very true. The grandiosity of the borderline fluctuates. The grandiosity of the psychopath is reactive. He becomes grandiose in certain situations while the grandiosity of the narcissist is a background noise. It's white noise. It's always there.

Additionally, says the DSM, the narcissist is less self-destructive, less impulsive, suffers less from separation insecurity or abandonment anxiety and is less emotionally dysregulated, emotionally hyper-reactive than people with borderline personality disorder and it's all very true, of course.

The DSM continues, excessive pride in achievements, a relative lack of emotional display and ignorance of or disdain for other sensitivities have distinguished Narcissistic Personality Disorder from histrionic personality disorder.

Although individuals with borderline histrionic and narcissistic personality disorders may require much attention, those with narcissistic personality disorder specifically need that attention to be admiring.

Individuals with antisocial narcissistic personality disorder share a tendency to be tough-minded, glib, superficial, exploitative and unempathic.

I want to clarify something here. The narcissistic supply, the attention can be positive or negative but it should be admiring. You should be awed by the narcissist. The narcissist should be perceived as awesome, awesome for his notoriety and infamy and cruelty and sadism and fearfulness and so on or awesome for his intelligence and accomplishments and altruism and so on but always awesome, always adulated and admired for positive traits and behaviors as well as for negative traits and behaviors.

The narcissist prefers to be feared and hated rather than be ignored but the fear and hatred should be imbued with being awestruck, being fascinated and amazed by the narcissist.

The DSM continues, narcissistic personality disorder does not necessarily include characteristics of impulsive aggressivity and deceitfulness.

You hear this? The narcissist is not necessarily deceitful. Narcissists don't gaslight. Psychopaths do.

Jesus, what a mess people are making online. I'm especially furious at the egregious misrepresentations by people with academic degrees who know nothing about these disorders and pretend that they do and leverage their degrees.

In addition, the DSM continues, individuals with antisocial personality disorder may be more indifferent and less sensitive to others' reactions or criticism.

And individuals with narcissistic personality disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood.

Now there are various considerations of mania or hypomania in bipolar, a staging bipolar disorder which imitates narcissism. There is an issue of substance use and how it affects narcissistic personality disorder and there is an issue of depression or persistent depressive disorder and how it manifests in narcissism, but I will not go into all this now. I will continue the differential diagnosis part.

It's F60.6, the code. The DSM says, in both narcissistic personality disorder and obsessive compulsive personality disorder, the individual may profess a commitment to perfectionism and believe that others cannot do things as well as he can.

In other words, he finds it difficult to delegate.

However, while those with obsessive compulsive personality disorder tend to be more immersed in perfectionism related to order and rigidity, individuals with narcissistic personality disorder tend to set high perfectionistic standards, especially for appearance and performance and to be critically concerned if they are not measuring up to these standards. In other words, narcissists put an emphasis on appearance, obsessive compulsive, place an emphasis on substance.

Suspiciousness and social withdrawal advises the DSM, usually distinguish those with schizotypal, avoidant or paranoid personality disorder from those with narcissistic personality disorder.

So the others are suspicious and they withdraw socially.

When these qualities are present in individuals with narcissistic personality disorder, they derive primarily from shame and fear of failure. Fear of having imperfections or flaws revealed the imposter syndrome. So narcissists withdraw when they anticipate failure, mortification, injury. They are deeply ashamed of themselves. They have an internalized bad object. They regard themselves as unworthy and inadequate and a walking, talking failure.

Narcissism is compensatory, not happy-go-lucky, not daring to. This is a psychopath.

The DSM continues, many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive and persisting, and only when they cause significant functional impairment or subjective distress, do they constitute narcissistic personality disorder.

This is Lynn Sperry's distinction between narcissistic style and narcissistic personality and narcissistic disorder.


The DSM continues, grandiosity may emerge as part of manic or hypomanic episodes in bipolar disorder, but the association with mood shapes or functional impairments helps distinguish these episodes from narcissistic personality disorder.

Narcissistic personality disorder must also be distinguished from symptoms that may develop in association with persistent substance abuse.

Experiences that threaten self-esteem can evoke a deep sense of inferiority and sustain feelings of shame, envy, self-criticism and insecurity in individuals with narcissistic personality disorder that can result in persistent negative feelings resembling those feelings seen in persistent depressive disorder.

If criteria are also met for persistent depressive disorder, both conditions can be diagnosed. This is something I've been saying for decades.

Narcissists do experience depression, but it is reactive, and the environment triggers in them dysphoria and shame. I have a video dedicated to it, which I posted a few weeks ago, two or three weeks ago.


What about comorbidity?

The DSM says, narcissistic personality disorder is associated with depressive disorders, persistent depressive disorder, and major depressive disorder, anorexia and anaphosa, eating disorder, and substance use disorders, especially related to cocaine. I would add alcohol, but it's more common in borderline. Histrionic borderline antisocial and paranoid personality disorders may also be associated with narcissistic personality disorder.

And now we come to the major breakthrough that didn't make it.

This should have been what I'm about to read to you. This should have been the new diagnostic dimensions for narcissistic personality disorder. They're included in the alternative DSM-5 model for personality disorders.

And here is what the DSM has to say about the alternative model.

The alternative model, says the DSM, is provided as an alternative to the extant personality disorders classification in Section 2. This is a hybrid dimensional categorical model in Section 3.

And it defines personality disorder in terms of impairments in personality functioning and pathological personality traits.

Inclusion of both models of personality disorder diagnosis in DSM-5 reflects a decision of the APA board of trustees to preserve continuity with current clinical practice, while also introducing an alternative approach that aims to address numerous shortcomings of the approach in Section 2 to personality disorder.

Okay, I'll try very hard to believe you.

For example, in the approach in Section 2 continues the DSM, symptoms meeting criteria for a specific personality disorder frequently also meet criteria for other personality disorders. And other specified or unspecified personality disorder is often the correct, but mostly uninformative diagnosis in the sense that individuals do not tend to present with patterns of symptoms that correspond with one and only one personality disorder.

That's the comorbidity problem.

By the way, there's another problem, the polythetic problem.

Since every five of nine criteria qualify you for a diagnosis, you and I can be diagnosed with the same personality disorder, but share only one diagnostic criteria.

Your personality disorder diagnosis would rely on criteria one to five, and my diagnosis would rely on criteria five to nine.

We could be as different as possible and yet be diagnosed with the same personality disorder, which is unconscionable. It's crazy. It's called the polythetic problem.

The DSM continues, in the following alternative DSM-5 model, personality disorders are characterized by impairments in personality functioning and pathological personality traits. The specific personality disorder diagnoses that may be derived from this model include antisocial, avoidant, borderline, narcissistic, obsessive compulsive, and schizotypal personality disorders.

This approach also includes a diagnosis of personality disorder trait specified. This is the approach of the 11th edition of the ICD, and such a diagnosis can be made when a personality disorder is considered present, but the criteria for a specific disorder are not met.

So what is the alternative model for narcissistic personality disorder?

By the way, you can find it in my book, in the latest edition of Malignant Self-Love and Narcissism Revisited, and you can also find these texts in the original DSM-5 text publication in 2013.

So narcissistic personality disorder, the alternative model, specifies typical features of narcissistic personality disorder are variable and vulnerable self-esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity. That's it, covert narcissism has officially made it into the DSM-5. Congratulations, it's been 33 years in the making.


The DSM continues, characteristic difficulties are apparent in identity, self-direction, empathy, and or intimacy as described below, along with specific maladaptive traits in the domain of antagonism.

So here are the proposed diagnostic criteria according to the alternative model.

A, moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas.

Area number one, identity, excessive reference to others for self-definition and self-esteem regulation, exaggerated self-appraisal, inflated or deflated or deflated, or vacillating between extremes.

Emotional regulation mirrors fluctuations in self-esteem, no core identity and the narcissistic self-idealization versus self-devaluation, all described in my work decades ago.

Area number two, self-direction, goal setting based on gaining approval from others, personal standards unreasonably high in order to see oneself as exceptional or too low based on a sense of entitlement, often unaware of own motivations.

Number three, I want to make a distinction here, narcissists are self-aware in the sense that they are fully aware of what they're doing, their actions, but the DSM is right, they are not aware of why they're doing what they're doing, their motivations.

Area number three, empathy, impaired ability to recognize or identify with the feelings and needs of other people, excessively attuned to reactions of other people, but only if perceived as relevant to self, over or under estimation of own effect on others.

Number four, 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.

Both of the following pathological personality traits should be present in a diagnosis, suggest the DSM takes revision.

Number one, grandiosity and aspect of antagonism, feelings of entitlement either overt or covert self-centeredness firmly holding to the belief that one is better than others, condescension towards others.

Number two, attention seeking and aspect of antagonism, excessive attempts to attract and be the focus of attention of the attention of other people, admiration seeking, traits and personality functioning specifiers may be used to record additional personality features that may be present in narcissistic personality disorder, but are not required for the diagnosis.

For example, other traits of antagonism, examples, manipulativeness, deceitfulness, callousness are not diagnostic criteria for narcissistic personality disorder, but can be specified when more pervasive antagonistic features are present.

And for the first time, the text uses the phrase malignant narcissism. This was first suggested in the 70s by Otto Kernberg.

They should take their time, the DSM committee.

Other traits of negative affectivity, example, depressivity and anxiousness can be specified to record more vulnerable presentations of narcissism, covert narcissism.

Furthermore, for the moderate or greater impairment in personality function is required for the diagnostic of narcissistic personality disorder, a level of personality functioning can also be specified.

In some ways, the text revision of the DSM-5 is uplifting. Covert narcissism made it finally into the text. Malignant narcissism made it finally into the text.

The recognition that women are equally as likely to be diagnosed with NPD as men finally made it into the text.

In this sense, the text is cutting edge. It recognizes that narcissism is a compensatory mechanism for a deep set feeling of inferiority, inadequacy and shame. It's a major evolution in thinking.

Similarly, the manual finally recognises that narcissists are not happy or lucky that they're egodystomatic and very, very likely to suffer from depressive disorders.

These are all major changes in thinking and diagnostic presentation and I welcome all of them, but it's not gone far enough. I feel let down by this revision because it did not go as far as the 11th revision of the ICD, recognizing that all personality disorders are facets of one underlying clinical entity and that people, through the mechanism of collapse, gravitate from one personality disorder to another or form one manifestation of personality disorder to another. They can gravitate from overt to covert narcissism, somatic to cerebral narcissism, and they can also gravitate from narcissism to borderline and back.

These co-morbidity and the polythetic problem, they go to show that a categorical approach to personality disorders is absolutely manifestly wrong. It's easier on the insurance companies and encourages, of course, the dispensation of psychopharmological drugs. It enhances the profits of several industries, but it has nothing to do with reality.

Men is not a category, men is not a list of diagnostic criteria, men is a river, men is in flux. My model of self-states, based on Philip Bromberg's work and others, is much more adaptable, reflects much more reality.

The DSM-5 in short is counterfactual and that's a great pity because they've almost made it. They almost got there and in the last moment they chickened out.

Maybe that in itself should be a new disorder. DSM committee membership disorder.

How about that? They have pathologized almost everything else from coffee drinking to the internet. Why not? Procrastination, avoidance, and fearfulness in the face of industries like the insurance and pharmacological industries.

I think it should qualify as a disorder.

What say you, members of the DSM steering committee?

Thank you for listening and as I said, this is the first in three. There'll be another one on borderline and another one on antisocial in due time if you stick by me a faithful and loyal and suffer my narcissism to its extreme.

You had been warned.

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