DSM V Alternative Model for Narcissistic Personality Disorder (NPD)

Uploaded 9/27/2014, approx. 11 minute read

My name is Sam Vaknin, and I am the author of Malignant Self-Love, Narcissism Revisited.

Last year, the American Psychiatric Association published the Fifth Edition of the Diagnostic and Statistical Manual, the bible of the psychiatric and psychological profession.

In it, it provided the diagnostic criteria for Narcissistic Personality Disorder on page 669.

Both the Diagnostic and Statistical Manual 4th edition text revision published 14 years ago and the 5th edition last year, define narcissistic personality disorder as a pervasive pattern of grandiosity, in fantasy or behavior, need for admiration, and lack of empathy, beginning in early adulthood and present in various contexts, such as family and work life.

The Diagnostic and Statistical Manual 5th edition, however, proposes two versions of Criteria for Narcissistic Personality Disorder. The first version is actually a copy paste from the 4th edition. Everything, the entire text, has been copied into the 5th edition.

Nine criteria, five of which must be met for a diagnosis of Narcissistic Personality Disorder to be rendered.

However, these criteria are deeply flawed, they are partial, and they do not reflect the knowledge accumulated over the last 14 years, both in academic research and studies, and in user communities and victim communities and communities of narcissists throughout the web, online and offline.

The criteria say, one, that the narcissist feels grandiose and self-important, exaggerates accomplishments and talents, but it ignores the fact that many narcissists also exaggerate learned skills, conducts, and personality traits, and that they do so to the point of outright lying and confabulation.

The criterion also ignores the fact that narcissists demand to be recognized as superior without commensurate achievements. It's not only that they expect to be recognized as such, but they demand vociferously and oftentimes aggressively.

The second criteria says that the narcissist is occupied or preoccupied with fantasies of unlimited success, but the narcissist's preoccupation borders on obsession.

The obsessive nature of the narcissist's involvement or self-involvement is absent from the criterion.

So the narcissist is obsessed with fantasies of unlimited success, but also with obtaining fame, with garnering fearsome power or omnipotence, with having unequal brilliance.

The cerebral narcissist, for instance, considers himself to be a genius. The somatic narcissist emphasizes this bodily beauty or sexual performance. All of them, both types, are concerned with ideal, everlasting, all-conquering love or passion, and all these dimensions of the narcissist's self-obsession and utterly fantastic self-image and self-perception are absent from the Diagnostic and Statistical Manual.

The third criterion says that the narcissist is firmly convinced that he or she is unique, and being special can only be understood by or associated with other special or unique or high status people or institutions, and that is very true.

But the criterion should be modified to include treatment. Narcissists insist on being treated by these high class, high status professionals, and this is reflected in medical professions, including in therapeutic settings.

The narcissist requires excessive admiration, says the fourth criterion, but the word adulation has been omitted and wrongly so. Narcissists are obsessed with garnering attention. They are looking for affirmation or failing that they wish to be feared and to be notorious.

The whole concept of narcissistic supply dispenses with value judgments, such as positive or negative. If the narcissist cannot be loved, he would rather be feared or hated.

The only thing the narcissist truly dreads is to be ignored.

The narcissist says the fifth criterion is entitled, and that is again very true. However, he demands automatic and full compliance with his or her unreasonable expectations for special and favorable priority treatment.

The narcissist is interpersonally exploitative, the sixth criterion. He uses others to achieve his or her own ends' goals. Using people is just the means towards an end.

The narcissist is devoid of empathy. That cannot be over emphasized.

If I had to choose a single criterion for pathological narcissism, it would be the narcissist's lack of empathy. The narcissist is unable or unwilling to identify with the feelings, needs of others.

But what the Diagnostic and Statistical Manual fails to mention is that the narcissist not only fails to identify with these needs and feelings of others, he fails to acknowledge them. He fails to accept them, and very often he fails even to notice them. Not only does he deny the preferences, priorities and choices of others, he denies the very existence of others.

As far as he is concerned, they are representations, cardboard cutouts, mere avatars on the inner screen of his mind.

The narcissist is constantly envious of others and seeks to hurt and destroy the objects of his or her frustration.

This is not sufficiently emphasized in the DSM. The narcissist, where the DSM completely fails to describe the narcissist properly, is that the narcissist suffers from persecutory, paranoid delusions, as he or she believes that other people feel the same about them.

The narcissist is essentially goal-oriented, goal-motivated. He is there to extract narcissistic supply.

And he believes that other people are exactly the same. He believes that they are envious of him. He believes that they are likely to act in a similar manner, and that renders him paranoid.

The narcissist behaves arrogantly and haughtily, and that's the last criterion, criterion number nine.

But this haughty or arrogant behavior is just the tip of an iceberg. The narcissist feels superior, omnipotent, omniscient, invincible, immune to the consequences of his actions, above the law, and omnipresent, magical thinking.

The narcissist rages when he is frustrated, contradicted, or confronted by people he or she considers inferior to him, and unworthy.

And all this is missing from the DSM, and is very critical.

The Diagnostic and Statistical Manual Five attempts to remedy these shortcomings and oversights by proposing what they call the alternative model of narcissism.

The alternative DSM-5 model for personality disorders is available on page 767. It says that the essential features of a personality disorder are impairments in personality, self and interpersonal functioning, and the presence of pathological personality traits.

And the DSM-5 goes to describe narcissism much more deeply than the DSM-4 has ever attempted. But still it falls short in certain fields, in certain areas.

The DSM says, for instance, that the narcissist keeps referring to others excessively in order to regulate his self-esteem. It should be sense of self-worth. It's only a question of self-esteem or self-confidence.

The narcissist feels worthless at one time or another, and worthy the whole world at another time.

So these fluctuations, these pendular movements between overvaluation and undervaluation, or devaluation of himself, this is the crux of the narcissistic disorder, of the narcissistic pathology.

So it's not only a question of self-esteem, it's a question of sense of self-worth.

The DSM-5 says that the narcissist uses external input, what I call narcissistic supply, to regulate his self-definition, to define his identity.

His self appraisal is exaggerated, whether it is inflated, deflated, or fluctuating between these two forms.

And the narcissist's emotional regulation reflects these vacillations, and it's all very true, and much more advanced than the DSM-4.

Finally, the DSM-5 accepted what I've been saying for decades, that narcissists can have an inferiority complex, actually, and feel worthless and bad, that they go through cycles of ups and downs in their self-evaluation, not only up, but also down, and that this cycling influences their moods and their affect.

The DSM-5 says that the narcissist sets goals in order to gain approval from others, and this is what I call narcissistic supply.

But the DSM-5 ignores the fact that the narcissist finds disapproval equally rewarding, as long as it places him firmly in the limelight and at the center of attention. The narcissist craves attention, and if he cannot obtain positive attention, negative attention would do.

The narcissist lacks self-awareness as far as his motivation goes, but he also lacks self-awareness as far as anything else goes.

The narcissist's personal standards and benchmarks, says the DSM-5, are either too high, which supports his grandiosity, or too low, which buttresses his sense of entitlement, which is incommensurate with his real life performance.

The DSM-5 mentions impairments in interpersonal function in either empathy or intimacy.

But the word or is wrong. The narcissist's flaw is impaired, is dysfunctional, when it comes both to empathy and to intimacy. It's not an either or. Both areas of life, both areas of personality, are highly dysfunctional with the narcissist.

Take empathy. The narcissist finds it difficult to identify the emotions and needs of others, but he's very attuned to their reactions when they are relevant to himself. And this is something that the DSM-5 notices.

I call it cold empathy. Empathy without the emotions.

Consequently, the narcissist overestimates the effect that he has on others, or underestimates the effect that he has on others. The classic narcissist never underestimates the effect he has on others, but the inverted and covert narcissist do.

Or take intimacy. The narcissist's relationships are self-serving. They are, therefore, by definition, shallow and superficial. These relationships of the narcissist are centered around and geared at the regulation of the narcissist's self-esteem.

It's another way of saying that obtaining narcissistic supply for the regulation of the narcissist's labile sense of self-worth is what narcissism is all about.

The narcissist is not genuinely interested in his intimate partner's experiences. That implies that he does fake interest convincingly, but it's fake.

The narcissist emphasizes his need for personal gain. And by using the word need, the DSM-5 acknowledges the compulsive and addictive nature of narcissistic supply.

And so the DSM-5 admits that these twin fixtures of the narcissist's relationships is the fact that they are self-serving and centered around the narcissist's sense of self-worth and self-esteem. And the fact that the narcissist is not genuinely interested in other people's experiences, including his insignificant others.

So if you put the two together, you see that the narcissist's relationships are rather one sided. There's no mutuality and no reciprocity, and of course, no intimacy.

The DSM-5 describes a series of pathological personality traits. It says that the narcissist is antagonistic, conflict oriented, and this is characterized by the narcissist's grandiosity and attention seeking. I would say ostentatious grandiosity.

The narcissist feels entitled because he feels grandiose. Feels that he's special, that he has a cosmic mission on earth, that he's unique. So therefore he's entitled.

The Diagnostic and Statistical Manual Five adds that such grandiosity can be either overt or covert, which corresponds to my taxonomy or classic and inverted narcissist.

Grandiosity is characterized by self-centeredness. It's a firmly held conviction of superiority, which manifests in potty and arrogant conduct, but it's also condescending and patronizing.

The attitude of the narcissist is that of a parent towards children. He knows best, he has more experience, he can teach us all.

The narcissist puts inordinate effort, time, and resources into attracting other people, I call it sources of narcissistic supply, and into placing himself at the focus and center of attention.

The narcissist seeks admiration, but the DSM-5 gets it completely wrong on this point.

The narcissist does prefer to be admired and adulated, but failing that the narcissist would settle for any kind of attention, any kind of attention would do even if it is negative.

The worst that can happen to a narcissist is to be ignored.

The diagnostic criteria in the DSM-5 end with disclaimers and differential diagnosis, which reflect years of accumulated research and newly gained knowledge.

The Diagnostic and Statistical Manual says that the above enumerated impairments should be stable across time and consistent across situations, and they should not be better understood as normative for the individual's developmental stage or socio-cultural environment.

Also, these impairments and dysfunctions are not solely due to the direct physiological effects of a substance, drug or medication, or a general medical condition such as severe head trauma.

Overall, the DSM-5 is a light years more advanced than the DSM-4 in subsuming and synthesizing current knowledge about narcissists, but there is still a very long way to go.

Maybe with the DSM-6, we could all lay back and say the academic profession, psychiatrists and psychologists finally got it. Twenty-five years too late, but better late than never.

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