You know that the diagnosis of narcissistic personality disorder exists only in the Diagnostic and Statistical Manual and in the Chinese CCMD, China's DSM?
These are two diagnostic manuals that cover the United States and parts of North America and China, about one third of the global population.
The rest of the world uses another book, another diagnostic manual, known as the ICD, International Classification of Diseases.
Its eleventh edition has been published about two years ago.
The publisher is the World Health Organization and variations and variants of the ICD rule the world.
Well over 80% of the human population are diagnosed with mental health issues according to the ICD, not according to the DSM.
Why am I telling you all this?
Because narcissistic personality disorder exists only, oddly, in the DSM and to some extent some variation in the CCMD.
There is no such thing as narcissistic personality disorder in the ICD.
In other words, four fifth of the human population reject the diagnosis of narcissistic personality disorder.
But what's wrong with these people?
Don't they acknowledge the existence of pathological narcissism?
What am I going to do for a living?
Should it be eliminated from the DSM as well?
I'm going to have to find another mental health issue and attribute it to myself, of course.
So seriously now, don't people in other countries in the world recognize the existence of pathological narcissism in its various manifestations, as a personality style, as a disorder?
The answer is they do.
What they don't recognize, what they reject is what is known as differential diagnosis.
In other words, breaking the mental illness continuum into discrete diagnosis.
This is what the DSM does.
It provides lists.
Some of the lists are categorical.
Other lists are dimensional on a spectrum.
But all the same, these are lists.
You go through the list and if you meet a certain number of criteria, you're diagnosed with a specific mental health condition.
And the mental health conditions are demarcated.
They're separate.
They're discrete.
They don't overlap.
And consequently, there's a problem known as comorbidity.
We diagnose many mental health issues in the same person, of the same patient.
Now I've been advocating for well over 30 years to eliminate these differential diagnosis and to put them together in one basket, a basket which I labeled personality disorder, a single basket.
I also suggested a bit later that personality disorders, many of them, not all of themdefinitely cluster B personality disorders and post-traumatic conditions and akin to addiction.
So they involve what used to be known as addictive personality.
Okay, enough about my work.
Let's talk about the ICD.
The ICD has adopted this approach, not because of me.
The ICD has adopted this approach.
And in the ICD, there's a single personality disorder with a variety of severities and a variety of traits.
And then what you do, like in a recipe, like in cooking, you take various ingredients and you combine them and you get the equivalent of the previous now discarded diagnosis.
So if you combine two or three traits with a specific type of severity, you get the equivalent of narcissistic personality disorder without calling it narcissistic personality disorder.
And according to the ICD and my work, if I may, transitions between allegedly or ostensibly disparate, discrete mental health conditions.
Transmissions are very common.
In other words, a narcissist is sometimes a psychopath and sometimes a borderline and sometimes a schizoid and sometimes a paranoid.
It's ridiculous to diagnose the same person with five mental health conditions.
There's no type constancy.
There's not even psychodynamic constancy.
Everything is reactive to the environment.
Everything is encoded in what I call, in the footsteps of Philip Romper, what I call self-states.
I encourage you to watch the videos on the DSM versus the ICD and the video on IPAM, intra-psychic activation model.
The links are in the description.
So in my world, which is essentially the world of the ICD, there's a single personality disorder and it manifests in a variety of ways throughout the lifespan.
There's no constancy.
And there are people who tend to display more specific traits than others.
So these people are more, for example, dissocial.
They are more negatively effective.
They're more commonly something.
And so we get a profile, we get a psychological profile of the patient.
Only we don't label the patient because these labels are counterfactual.
They're a fantasy.
They're wrong.
And every practitioner will tell you that the vast majority of these labels are idiotic.
They fly in the face of evidence.
It's not evidence-based and it's not medicine, of course.
The reason is that the DSM was written at the behest and request of insurance companies and pharmaceutical companies.
So it doesn't reflect the current knowledge in clinical psychology.
The ICD is about 25 years more advanced than the DSM.
The DSM attempted to introduce alternative models of personality disorders in appendices at the end of the book.
And they're nice, but they still preserve the concept of differential diagnosis and the list-like attributes, list of diagnostic criteria.
So, wrong, wrong approach.
People are rivers.
They flow.
They're in flux.
They can't be captured in a single diagnostic basket with a list.
That's not how people work.
That's not how the human mind works.
So now today there's a video, and like everything Jewish, it's divided in two parts.
The first part is for laymen.
The second part is for professionals.
But you're welcome to watch it, if you wish.
I will start by giving a broad overview of the ICD's approach to narcissistic personality disorder.
Remember, there's no such thing, no such diagnosis as narcissistic personality disorder or borderline or anything else, by the way, in the ICD.
Still, we can construct a profile of an emotionally dysregulated person, emotional EUPD.
We can construct a profile of a narcissist using the tools provided by the ICD.
When it comes to borderline, by the way, there is something called EUPD, which has to do with emotional dysregulation rather than the classical, Könberg style borderline picture.
So as you see, there is a cousin, there's an abyss between the United States, the West, not the West, but the United States and the rest.
And so I'm going to explore this abyss today from the point of view of the rest, not the United States.
And I'll start with an overview for Lehman.
The ICD 11, the 11th edition of the ICD has diagnostic criteria for borderline pattern of personality disorder or what they call personality difficulty.
The ICD describes three levels of personality disorders.
The first question is, does the person have a personality disorder that fulfills the definition criteria?
The second question though is what is the level of severity of the possibly diagnosed personality disorder?
And the third level is, are there trait domain specifiers?
In other words, domains that describe the characteristics of the individual's personality that are most prominent and contribute to a personality disturbance.
In other words, the ICD's philosophy is that everyone has characteristics and traits.
And when these go awry, when these are exaggerated or out of control, only then do we have a mental health issue with a personality.
So it's a very interesting approach because in the ICD, mental illness emerges organically from mental health.
It's not an exaggeration of mental health.
It's not a caricature of mental health, but it does emerge from mental health.
Now the ICD focuses on global and shared features that apply to all personality disorders.
I'd like to read to you the definition of personality disorder in the ICD 11.
It is in some respects preferable and superior to the definition in the DSM.
They say, "Personality disorder is a marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption.
The central manifestations of personality disorder are impairments in functioning of aspects of the self, such as identity, self-worth, capacity for self-direction, and/or problems in interpersonal functioning, for example, developing and maintaining close and mutually satisfying relationships, understanding others' perspectives, managing conflicts in relationships.
Impairments in self-functioning and/or interpersonal functioning are manifested in maladaptive, in other words inflexible or poorly regulated patterns of cognition, emotional experience, emotional expression, and behavior.
Every disturbance has three levels of severity.
Once a diagnosis of personality disorder has been established, it should be described in terms of severity.
Is it mild?
Is it moderate?
Or is it severe?
And according to the ICD 11, personality disorder and personality difficulty can be further described using five trait domain specifiers.
Now what they call personality difficulty is what Len Sperry and Theo Domilen and others call personality style.
Okay, these are the trait domains.
So what are trait domains in the ICD 11?
I'm quoting.
These trait domains describe the characteristics of the individual's personality that are most prominent and that contribute to personality disturbance.
As many as necessary to describe personality functioning should be applied.
Now there are quite a few domain specifiers, I will mention a few.
Negative affectivity, detachment, dissociality, disinhibition, and encasement.
So I will deal with an encasement and dissociality in a minute.
So how can we capture the equivalent of narcissistic personality disorder in the ICD 11?
We are not denying, no one is denying that there are people who are harmful to others owing to something that could be described as narcissistic personality disorder.
There's no denying this.
So how do we capture it diagnostically with the tools and instruments provided by the ICD 11?
So first of all, the ICD makes clear that narcissistic personality disorder can be either mild or moderate or severe and that it's possible to have narcissistic personality difficulty versus a narcissistic personality disorder, although the ICD does not use the word narcissistic or narcissism, at least not in the main text.
So the trait domains that are relevant to narcissism are dissociality and anachastia.
And I will explain the trait domain of dissociality creates narcissistic features with an emphasis on self- centeredness.
How does this sociality manifest in daily life, in relationships with others, and even more importantly, in relationships with oneself?
First of all, there's a sense of exploitativeness towards others.
What can they do for me?
How can I extract benefits from other people?
Then there is the belief that you deserve whatever you want, and it should be obvious to others.
So if you are dissocial, you have a sense of entitlement, the expectation of admiration from others and engaging in attention seeking behaviors, becoming angry or denigrating others.
This is not only in the DSM as antagonism, when you don't receive expected admiration and attention.
The belief that your accomplishments are outstanding and have many admirable unprecedented qualities and a strong belief in the potential for greatness, expectation of others to admire you for your incipient greatness.
These are all elements of dissociality.
Now Bach, B-A-C-H, Bach, the composer and his associates in 2022, expanded on it.
They said that someone with dissociality and an encasement is likely to have a fluctuating self-view, alternating between overly positive and overly negative.
Narcissistic individuals may struggle to recover from damage to their self-image.
They often exhibit poor emotional regulation and have difficulty developing close relationships.
Other sided conflicts and dominance may characterize their relationships.
Some narcissistic individuals may struggle to maintain regular work conditions or collaboration.
Narcissistic individuals may also exhibit traits of perfectionism, vanity and negative affectivity.
Now when you put perfectionism and vanity together, this is an encastia.
An encastia is an attribute, an element in obsessive compulsive disorders, especially in the compulsion.
So an encastia is perfectionism coupled with vanity, being proud of your perfectionism.
And this fits well with OCD, obsessive compulsive disorder, but according to the ICD, it characterizes narcissism as well, although again, they don't use the word narcissism.
So Bach and his co-authors said that the combination of dissociality, an encastia and negative affectivity may indicate distinct features of narcissism, including the factualistic overcompensation and rule-bound narcissistic dominance.
Negative affectivity may include vulnerability, depression, anger, hostility and shame features suggestive of vulnerable manifestations of narcissism.
The combination of dissociality and negative affectivity traits in the ICD may indicate vulnerable narcissism in individuals who ruminate over perceived slights, overreact to criticism and have low frustration tolerance.
Their low self-esteem may lead to envy of other success and be driven by past failures and procrastination experiences.
Different scales can capture various facets of narcissism, such as grandiosity, need for admiration, vanity, arrogance, selfishness, reactive anger, shame, self-centeredness, lack of empathy and entitled superiority.
All these emanate, emerge, as I said, organically and naturally by combining the various domain-specific traits in the ICD so we get an excellent, full-fledged description of narcissism without using the word "narcissism".
Because when we say "narcissism", we are committing ourselves to a diagnosis and we're excluding other diagnoses.
This is not what the ICD is all about.
The ICD says exactly the opposite.
We should incorporate all possible diagnoses without regarding them as separate clinical entities.
They are not separate clinical entities.
They're just a human being trying to cope with the environment by somehow controlling and managing his traits or her traits.
The traits of course determine how one copes with the environment.
The traits determine how dysfunctional or functional one is.
The traits determine if one is perfectionistic or one is vain.
The traits determine your characteristics and behaviors.
Of course, you are given some kind of equipment.
This equipment is either genetic or environmental.
It's either an outcome of upbringing or an outcome of brain abnormalities, whatever the case may be.
This equipment, your domain-specific traits and the severity of your personality dysfunction or difficulty or disorder, they determine your behavior.
But we cannot pigeonhole people.
We cannot put them in boxes because people are phenomenal in flux.
They are constantly evolving, constantly reacting, constantly changing.
And you cannot capture them with a list of nine diagnostic criteria.
In this sense, the ICD is considerably more advanced than the DSM.
This was the part for the layman.
Now you can sign off if you wish.
Although, I think you may find some of the things I'm about to say interesting, even though they are directed at professionals, you may find some of them interesting.
Narcissism is a psychological concept.
It is characterized by self-adoration and disregard for the needs of others.
These are the behavioral manifestations.
In my work, I postulate that narcissism has to do with two major problems, a disruption in the formation of the self and an inability to recognize the separateness and externality of other people.
So this gives rise to all the the monopoly of manifestations of narcissism, lack of empathy, exploitative and so forth.
Now narcissism is nothing new.
The clinical manifestations of narcissism has been expertly and perfectly described.
In scriptures such as the Old Testament, the New Testament and the Quran, among others, narcissists have been around since the first step taken by Homo sapiens.
I'm sure there were chroma neurons and Neanderthals who were narcissists.
So this is nothing new clinically speaking.
Narcissism is an organizing principle.
It's an entirely different story and I will deal with it with another video this week.
Now narcissism is a source of concern because exactly as the ICD says, it's desocialit with another video this week.
Now narcissism is a source of concern because exactly as the ICD says, it's desocial or the DSM uses the term antisocial.
Narcissists wreak havoc on other people, on institutions, on structures, on the social contract, on everything around them.
They're very self-destructive and they're very other destructive.
Even if they enjoy a period of success and ostensible accomplishment, they're going to ruin it.
At the end, they're going to ruin it somehow.
So the origins of narcissism can be traced back as far as the myth of narcissus, Ovid's myth, narcissus in metamorphosis.
There was like 2,020 years ago.
And you know, in this myth, there's a Greek youth and he falls in love with his own reflection, not with himself, mind you, with his reflection, with his false self, because he's unable to merge with his false self and to become one with it, he wastes away and dies.
Today, by the way, we would describe narcissus, the youth, not as an overt narcissist, but as a covert narcissist, just something fun to ponder while you drink your coffee.
So the term narcissism was first coined not by Freud, but by Ellis in 1898.
At that time, it was confined to auto-erotism or auto-eroticism.
In other words, a sexual perversion, where an individual becomes sexually fixated on themselves and sexually attracted to their own bodies.
It was considered at the time a deviance.
And so it was pathologized, this kind of attraction was pathologized and Ellis gave it the name narcissism.
Now this narcissism hasn't lost throughout the following centuries or decade, a century and a half.
Narcissism hasn't lost this particular aspect of it.
All narcissists are auto-erotic.
All of them are psychosexually attracted to themselves.
All of them have sex with others by converting these other people into internal objects.
So when they have sex with other people, they're actually having sex with internal objects within their mind, with themselves, in other words.
The most widely accepted definition of narcissism is Hartman's definition in 1950.
He described it as the "libidinal investment of the self", which is just a rendition of closely aligned with Freud's original formulation.
Freud said in his essay on narcissism and introduction in 1914 that the narcissist directs his libido inwards, at himself or herself, and Hartman just codified it.
Freud's theory was very interesting in some respects because he tried to construct a physics equivalent in psychology of a physics kind of theory, a theory in physics.
He said that there's energy, some kind of energy in the body.
Later it was called kafexis, the act of investing this energy, was called kafexis, a word which Freud abhorred and hated, by the way.
Anyhow, Freud said everyone has a fixed amount of energy, libido, life energy.
The life energy includes a sexual element, the sexual drive, known as eros.
According to Freud, when libido is directed towards other people, it's object love or object libido.
When it is directed towards oneself, it manifests as narcissism.
And this distinction is a fundamental aspect of Freud's understanding of narcissism and the relationship to others, object libido.
According to Freud, the narcissist, the adult narcissist, is simply incapable of directing libido, including sex drive, towards other people.
He's incapable of what came to be known decades later as object relations.
Now, many of these theories and ideas have been discarded, I regret to say, because I find a lot of merit in some of them, not all of them, but some of them.
All of them have been discarded when psychology attempted to become a branch of medicine, kind of science.
Psychology is, of course, a pseudoscience, you know my point, my view.
Nowin the 70s, Könberg came up with a new concept of narcissism, which is best described in Russell's work in 1985.
He said that pathological narcissism involves a pathological self structure, the grandiose self, also known as the false self.
It's a defense against rage and envy and shame.
Könberg didn't dwell on shame. Shame was added later by others.
So it's a defense.
There is a pathological self structure that serves as a firewall, as a fortress, against these emotions, against these negative effects inside that can ruin the narcissist if he were to get in touch with them, without the protection of the false self or the grandiose self structure.
According to Könberg, normal immature narcissism is not the same as pathological narcissism.
And finally, narcissism is a subtype of borderline personality disorder, according to Könberg.
Ironically, Könberg's view came to dominate.
And today we do, with the exception of the DSM, we do believe that all cluster B personality disorders are facets of a single clinical entity.
The vast majority of scholars tend to believe this.
And this is reflected, of course, in the ICD.
Könberg's view prevailed compared to Kohut's view.
Kohut's view of pathological narcissism, again summarized in Russell's work in 1985, was different, dramatically different to Könberg's.
Kohut is the father, he coined the phrase of narcissistic personality disorder in 1974, 1975.
Both giants were at work in the same years.
And Kohut's view of pathological narcissism is that it involves a fixation at an early stage of narcissistic development.
"Normal immature narcissism is the same as pathological narcissism," said Kohut.
"There's no such thing as healthy narcissism."
Now, today we disagree with this vehemently.
Again, Könberg prevailed, not Kohut.
And finally, Kohut said that there is a clear distinction between narcissistic personality disorder and borderline personality disorder.
They're absolutely not the same.
Kohut and Könberg agreed, though, that pathological narcissism involves a defective self of some kind and is influenced by disrupted attachment experiences.
This was later developed by Bauelbe and others in attachment theory.
So the emphasis was on what came to be known in Winnicott's term, the good enough mother-child symbiosis, which gives rise to healthy narcissism.
Pathological narcissism is when the mother is either not good enough or when the mother is good enough, but the symbiosis has been somehow disrupted.
She died, she got sick, she got depressed, whatever the case may be.
These are two developmental pathways on the way to narcissism, pathological narcissism, because narcissism lacked this secure base nurturing bond with the mother figure.
According to Russell, Könberg in 1970 maintains that narcissistic personalities often experience their parents as callous and indifferent.
There is consistently a parental figure, usually the mother, who functions well on the surface, but with a degree of non-verbalized spiteful aggression, said Könberg.
Schroeder, summarized in Feinstein, said that individuals with narcissistic personality are grandiose and entitled, dismissive and critical of others, and often show underlying signs of vulnerability beneath a grandiose facade.
And this came to be the dominant position today.
Today we believe that most narcissists, if not all narcissists, are actually vulnerable.
They have what Adler called an inferiority complex.
They have a core that is composed, comprised of shame and internally directed rage and anger and resentment and self-loathing and so on, and they're trying to compensate for it by pretending to be everything which they are, everything opposite to who they are.
So the facade, the false self, the grandiose firewall or fortress that surrounds them, the shell, the grandiose shell, is just a compensation for what really goes on inside them, which is intolerable.
In modification, the facade crumbles, the false self is disabled, deactivated, and the narcissist gets in touch directly with this reservoir of life-threatening shame and rage.
So this is the mechanical model of narcissism.
Now in narcissism, there is a group of well-identified defense mechanisms that operate habitually.
They've been described by Russell in 1985, Millen and others in 2012, and so on and so forth.
These defense mechanisms are idealization, devaluation, denigration, unconscious repression, unconscious denial, omnipotence, distortion, including cognitive distortion, exaggeration, minimization, rationalization, confabulation, these all create an impaired reality testing.
Psychological projection, blaming some other people, alloplastic defenses, enlisting the help of one or more codependent friends who will support the distorted view is very common.
So the defense mechanisms often rely on a shared fantasy.
The defenses operate optimally in a shared fantasy because shared fantasy isolates the narcissist and a few like-minded people from reality, and this creates self-enhancing and self-augmenting confirmation bias.
Now malignant narcissism is a combination of narcissistic and antisocial psychopathic traits.
It involves narcissistic grandiosity, sadistic aggression, demeaning, degrading and defeating other people is necessary for the narcissist to feel important.
A recent overview of malignant narcissism is Feinstein in 2022.
Now malignant narcissists lack an internalized moral system, so they are amoral.
They sometimes act immorally, but that's because they have no morality, not necessarily because they are the evil of issues.
They exploit other people, they harm other people, and they experience no remorse whatsoever for doing so, and this sets them apart, for example, from people with borderline personality disorder, and even from other narcissists.
It is a common myth that narcissists are unable to experience remorse or regret.
That is psychopaths.
Psychopaths and malignant narcissists are like that.
The vast majority of narcissists do experience remorse and regret.
They have defenses that push away the remorse and the regret.
Morrison described the interplay between shame, guilt, remorse and regret within the narcissist's psyche and how they are all repressed and denied.
Malignant narcissists externalize blame, alloplastic defenses.
They refuse to take responsibility for the consequences of their actions.
There's a convergence here of psychopathic traits, psychopathic behaviors, and propensities such as defiance, recklessness, consummation, rejection of authority, psychopathic deception, exploitation, sadistic aggression, externalization of aggression, and other features with narcissistic grandiosity, self-importance.
All in all malignant narcissists are very, very destructive.
It is a common view, and mine as well, that malignant narcissists are far more dangerous than psychopaths and definitely, definitely, infinitely more dangerous than narcissists, than plain vanilla narcissists.
Because a malignant narcissist uses psychopathic tools and behaviors to obtain narcissistic goals.
And one of these narcissistic goals is narcissistic supply, but the other is self-destruction, self-punitive, creating a self-punitive cycle.
And so a malignant narcissist would take everyone around him into Valhalla, the way Hitler did, the way to some extent Trump did.
He would take everyone with him into hell as he destroys himself, the fantasy that he has constructed, the environment in which a fantasy is embedded, and he does it with deception, exploitation, sadism, aggression, and grandiosity, and self-importance, and so on and so forth.
Goethe der Moen, the Twilight of the Gods, and if you want better insight into these dynamics, then I recommend definitely Dostoyevsky and Nietzsche, of course.
They are the greatest psychologists who have ever lived, by the way.
Now, let's then go deeper into the ICD's view of all this mess.
You remember that the ICD allows us to characterize pathological narcissism as either mild, moderate, or severe.
It creates a lot of flexibility.
There's a spectrum there of narcissistic disturbances of the self, or of character, or morality, depending how you look at narcissism.
This fits well with everything I have been saying and now others are saying.
I'm not implying anything.
There is a spectrum of pathological narcissism.
Len Sperry, of course, suggested the distinction between personality style, personality disorder, which is widely accepted today, and Milan upheld this view in his magnum opus, Personality Disorders in Daily Life.
The self view of narcissism, according to the ICD, now we are in ICD territory.
The self view of narcissism can vacillate between overly positive and omnipotent, and are extraordinarily negative and devastating.
This depends on the specific nature of the disorder.
Is it grandiose or is it vulnerable?
In the ICD, these features emerge, as I said, organically and naturally as an outcome of the interplay between domain specific traits.
Narcissistic individuals have difficulty to recover from injuries to grandiose and vulnerable self image.
This is why today we consider overt grandiose in your face, happy-go-lucky narcissists to be actually psychopaths, not narcissists.
Narcissistic people exhibit poor emotional regulation in the face of setbacks.
In this sense, there is some affinity between narcissists, a huge affinity, because emotional dysregulation defines borderline personality disorder.
There is a great affinity between narcissism and borderline, exactly as Köhlenberg had suggested so many decades ago.
The self-focus and callousness of narcissists may compromise the quality of relationships.
For example, they ignore other people's opinions, they exploit other people.
And this contributes to difficulties in developing close, mutually satisfying and intimate interpersonal relationships.
The relationships of narcissists are characterized by volatile conflicts.
These conflicts are usually one-sided.
The narcissist tries to assert dominance, tries to be always right, tries to sustain his sense of infallibility and perfection.
We'll come to that a bit later.
To maintain this sense of perfectionism or sense of godlike perfection, the narcissist argues all the time, imposes conflict on situations which would have never led to conflict with healthy people.
So, the conflicts are very one-sided.
And a subgroup of narcissists are unable to sustain work conditions, teamwork, collaboration, marriage or even to bring up children because they keep introducing aggression and conflict into utterly innocuous situations.
Now, according to the ICD, narcissistic features are mainly characterized by the trait of dissociality with emphasis on self-centeredness.
The pattern of dissociality involves, as I said before, exploitativeness of others, believing and acting as if you deserve anything you want, entitlement.
These features of narcissism are manifested as an expectation from others.
The narcissist has a list of expectations.
Entitlement is the active expression of this list of expectations.
Entitlement is when the narcissist tries to impose on other people his list of expectations.
And then when they don't comply with the expectations, when they are not sufficiently malleable or submissive or people pleasing or codependent or whatever you want to call it, the narcissist becomes aggressive, viciously aggressive.
If he's a malignant narcissist, he becomes a sadist in effect.
So the narcissist goes around with a list of expectations pinned to his sleeve and he presents his expectations to others and he expects them to immediately drop everything and comply.
Admiration, attention seeking, justification to tell the narcissist you're always right, you're the greatest and so on and so forth.
These constitute an integral part of such a list of expectations and having such a list of expectations and coercing others to comply with such a list, that's part of the sociality.
Now these lists are sometimes overt and explicit.
The narcissist can come to you and say, "Do you agree that my work is groundbreaking and revolutionary and that I'm a genius or don't you think I'm drop dead gorgeous?" I mean, as simple as that.
And the list could be implicit.
For example, in the shared fantasy, there is a list of expectations.
The narcissist idealizes other people, his intimate partner, his friends, whatever, and then he expects them to conform to the idealized image, to the idealized version.
That's what is called a hidden text.
He has an overt text and a hidden text.
There's a hidden text of expectations.
I've idealized you, now act the way I expect you to conform to your idealized version.
Don't deviate, don't diverge, don't challenge it, don't undermine it.
If you do, I'll punish you.
I'll punish you severely.
The aim of all this is attention.
Narcissistic supply.
Narcissists are addicts.
They're junkies.
They're addicted to narcissistic supply.
They aim to remain the focus, the center of other people's focus.
And they become angry and they denigrate others when the admiration and the attention are not granted or insufficient or low grade or fake.
So narcissistic individuals believe that their accomplishments are outstanding, that they have many admirable qualities, that they have or will achieve greatness, maybe post-mortem, posthumously, and that others should realize all this because it's so clear and admire them for it.
Or fear them, by the way, doesn't have to be positive supply, could be negative supply, to be feared is supply, is a form of supply, to be envied is a form of supply.
So the dissociality trait in the ICD, the domain specifier, the trait domain specifier, doesn't appear specific to narcissism.
So many people criticize the ICD and they say the traits are too white, too all encompassing, too fuzzy, too blurred.
To serve, they don't, consequently they cannot serve well as diagnostic tools.
But I disagree.
I tend to disagree.
It is not the traits that should serve as diagnostic tools.
It is the combinations of the traits.
When you begin to combine traits in a variety of permutations, you get very fine-grained, fine-tuned diagnosis.
Very fine-grained and fine-tuned than the DSM, in my view.
Anyhow, the trait domain specifiers, of course, are not unique to narcissism or specific to narcissism or to borderline or to anything.
That's the greatness of the ICD.
The ICD gives you Lego bricks.
You build your own castles, diagnostic castles.
For example, it characterizes dissocial personality disorder, known as antisocial personality disorder, in the DSM, kind of psychopathy.
Many people with the diagnosis of narcissistic personality disorder, in order to keep up with the subjective sense of superiority, are also characterized by the trait domain of unencastier.
So dissociality is not enough to capture the essence of narcissism.
You need to combine it with unencastier.
Unencastier, simply put, is rule-based, rigid perfectionism coupled with vanity, pride for being perfect, proud for being perfect.
So this is unencastier.
Unencastier enhances competitiveness, upholds and buttresses self-esteem, and creates grandiose self-representations.
So if you combine an unencastier and dissociality, you get narcissism.
So the narcissist, according to the ICD, narcissism is a perfectionistic overcompensation and rule-bound dominance over others in order to exploit the sources of narcissistic supply, partners in shared fantasy, and so on and so forth.
Now, additional features which can be tacked on to and added to an unencastier and dissociality, an additional feature is negative affectivity.
Negative affectivity gives rise to vulnerability, depression, anger, envy, hostility, shame.
So negative affectivity captures the vulnerable manifestations of narcissism.
Now, we know today that all narcissists are both overt and covert.
There's no type constancy.
Narcissists cycle between overt phases and covert phases and overt phases and covert phases interminably.
This is known in practice.
However, in academe, they still make a rigid distinction, a partition between overt grandiose and covert vulnerable.
So there is a gap, there is an abyss and a huge debate between practitioners in the field and academics, academicians and theoreticians.
The reality is, of course, that all narcissists are both overt and covert.
Anyone who has worked with narcissists for more than 10 minutes can tell you this.
But unfortunately, that's not what you find in textbooks and in the majority of articles and so on and so forth.
So it's very misleading.
The literature is very misleading currently.
ICD is the first official diagnostic text, diagnostic manual that combines vulnerable and grandiose narcissism into a single entity by putting together traits such as dissociality, negative affectivity and anhedonia.
The ICD is far more realistic and far more flexible and far more factual than the DSM, actually.
So when we combine dissociality and negative affectivity, we get vulnerable narcissism.
These people ruminate over perceived slides and insults from other people. They're overreactive to criticism. They have low frustration tolerance and they become overtly or covertly upset over minor issues.
We all know such people.
The low self-esteem involved with vulnerable or covert or shy or fragile narcissism, this low self-esteem manifests usually as envy of other people's success, other people's abilities, other people's traits, other people's looks, other people's possessions, happiness, you name it.
And it is also driven by shameful experiences of repeated failures and procrastinations in the lives of vulnerable narcissists.
In other words, it is driven by collapse, repeated collapse.
Now, I'm not denying that some narcissists are much more covert than overt.
Even though there's no type constancy, one type is dominant and the other is recessive.
A typical covert narcissist would spend 80% of his life being covert and only 20% being overt and vice versa.
Same applies to somatic versus cerebral narcissists.
I have spent 80% of my life being cerebral and only 20% being somatic.
So if you take all these together, the individual manifestations of narcissism are captured perfectly by distinctive combinations of trait domains where this sociality is perhaps the main ingredient and then the garnishes, the added traits are negative affectivity and anhedonia.
Narcissistic features can also be illuminated by scales developed in order to capture ICD-11 trait facets and nuances such as grandiosity, the need for admiration, vanity, arrogance, selfishness, reactive anger, shame, self-centeredness, lack of empathy and entitled superiority.
And there are quite a few instruments and scales developed for these purposes specifically.
Okay.
That's where we are today.
There's two major debates.
There are three major debates.
One covert versus overt.
Are all narcissists both covert and overt?
Or is there type purity across the lifespan?
The second argument is between criteria, diagnostic criteria, which are either categorical or dimensional and the ICD type of model.
And so these debates are tearing the community apart.
There's a growing gulf between the online world and practitioners and academics and theoreticians.
And finally, there's a debate between this discussion of whether overt narcissism, grandiose narcissism is not actually a form of psychopathy.
In other words, is all narcissism compensatory?
Or do we have a kind of narcissism that is not compensatory?
Do we have narcissists who truly believe that they're the greatest gift to humanity, godlike?
Or is it all a kind of compensation for an inner sense or inner conviction of inferiority, what I call a bad object?
These are the debates.
So stay tuned.
And let's see what happens to narcissistic personality disorder in the sixth edition of the Diagnostic and Statistical Manual.
The DSM-5 committee almost removed narcissistic personality disorder from the manual, almost.
And then ironically, it left it in and added to it an alternative model.
So now many more pages are dedicated to narcissistic personality disorder in the fifth edition of the DSM text revision than in the fourth edition of the DSM text revision.
Now, NPD is spreading, didn't I tell you it's contagious?
Even the DSM committee is not immune to its charms.