On Diagnoses of NPD.


Background

In the previous submission we learned that a person has to have impairments in personality (self and interpersonal) as well as have pathological personality traits (erratic traits that society rejects that aren’t optimal to functioning) present in order for us to use the “disorder” label.  These impairments in personality are at the ‘self’ level affecting identity and self-direction as well as the ‘interpersonal’ level where empathy and intimacy plays a role (see Table 2).  Here we will use the diagnostic criteria we see in DSM 5 part II (see Table 1) to point towards a diagnoses based on the trait model but will also integrate section III’s model since it is much more insightful.

I’m sure I can read on the practice of how to diagnose and assess until I turn blue in the face but to truly be a good clinician takes actual experience, which I don’t have.  But I’d argue that in some sense I’m actually at a much better position to making an accurate diagnosis than a practitioner is as I have observations that stretch over ten years, which exclude the narcissist’s confessions to a therapist which are often contrived and of little value.  In fact, I am providing a very rare opportunity at looking at how a narcissist thinks because NPD is the least studied of personality disorders and many variations exist making it confusing and difficult to diagnose.

Method Used

Unfortunately there seems to be a lack of rigor and protocol to diagnosing that confirms my overall impression that I have had on the profession, and I say this in the most respectful way because I know it’s a social and behavioral science making variables more difficult to capture and measure.  But look at the first criterion (Table 1) and notice that there’s nothing to distinguish between how strong (severity or magnitude) or how often (frequency) the effect is.  So this makes me concerned about conflating the disorder with just having the trait.

And besides there being no attempt on capturing how often these nine tendencies show up over time, there’s also no way of characterizing the quality of how the traits are expressed under certain conditions which may be important.  I did, however, find a questioner that puts it in on a five point scale ranging from very often to never, which I decided to use.  But we don’t have access to the person’s personal thoughts and feelings, and she is socially skilled enough to know how to hide her unattractive ego with others.  So what are we relying on as data?

What I did was estimated an answer shown in the criteria scale below under Table 1 based on the degree and frequency of her  demonstrating these traits as seen in her actual behavior and in odd things that she’s uttered.  These utterances were in unique contexts that when extracted, I would argue, give lots of information about her inner workings.  She also had a very well hidden but highly developed ego, which could be quite disturbing, often coming across as if that were her authentic-self making all other sides to her seem but a facade.  

It was in these moments of egotistical truth, however, that revealed a highly insecure person that was very much attuned to my place, your place and her place in the social hierarchy so as she can best strategize her moves in her limitless quest for power and attention.


Table 1. Trait Model (DSM 5 section II)

  1. Has a grandiose sense of self-importance. (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, ideal love.  
  3. 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).
  4. Requires excessive admiration.
  5. Is interpersonally exploitative. (i.e., takes advantage of others to achieve his or her own ends)
  6. Has a sense of entitlement.  (i.e., unreasonable expectation of especially favorable treatment or automatic compliance with his or her expectations)
  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.  
  9. Shows arrogant, haughty behaviors and attitudes.

Explanation of Traits

The essence of grandiosity I take as to be the desire to feel “important” which can easily fall into a feeling of superiority.  The emotions involved here are those of the self-conscious type – namely pride and shame – which help us to function in social situations by making us aware of how we come across to others.  So important only makes sense in social contexts because it has to do with how we rank relative to one another.  And one of the reinforcers of feeling important – making you want to do it – is to feel the emotion of pride, but once you start comparing yourself in a superior way, then you will feel the inflated pride of a narcissist known as hubris.

The next trait is having the tendency of idealizing, fantasizing or romanticizing.  The kernel in these activities has to do once again with feeling important, special and powerful.  What happens is that we fantasize how perfection would be in the future – say the ownership of many houses or to be in the presence of a perfect lover – and we relish those feelings of pride and feelings of being special through our imaginations.

The third trait has to do with how important it is to associate with high-status others to affect your self-esteem.  This is where the trait model found in section II shows its limitations, so I will mention section III, the hybrid model, shown in Table 2 below, that works with dimensions instead of traits that could be integrated into this analysis for more insight.


Table 2. Hybrid Model (DSM 5 section III)

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

1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem.
2. 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.
3. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.

B. Both of the following pathological personality traits:

1. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others.
2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking.


To shed light onto the need to feel ‘special’ to the point of exclusively associating only with other high-status individuals, we need to see how we manage our self-definition and self-esteem.  If we rely too heavily on our associations to define ourselves or to manage our self-esteem, this can become maladaptive and is listed as an impairment in personality (Table 2, A, 1).  We will discuss why this is maladaptive in the post that focuses on causes and consequences of NPD.

The trait of excessive admiration is something that can be hard to see since it’s often a hidden requirement in narcissists, but it seems to be an important need to be not necessarily well liked but more importantly well respected and looked up to by others.  And jumping to the last two traits from Table 1, we can see that they will feel envious often or believe others are envious of them, which captures feelings of resentment and discontent over others’ achievements or possessions.  The ninth trait of arrogance is related to trait one of grandiosity but the focus seems to be on displaying it where you exaggerate your significance (inflate yourself) and importance by posturing around others and can even show attitudes of disdain toward those that don’t meet your standards.

The last three traits to discuss are impairments in empathy, exploitation of others and a sense of entitlement.  These in my view are the consequences of having narcissism as in they affect those around you.  It’s not that they don’t have the ability to be empathetic and often do but more often than not it’s in a self-serving way.  The exploitation of others then comes natural with low empathy, and people often become objectified and used as a means to accomplishing their goals.  And, lastly, a sense of entitlement means I deserve it because I’m important not because I earned it.


References

[1] Buss, David M.. The Dangerous Passion: Why Jealousy Is as Necessary as Love and Sex. Free Press.

[2] Dziegielewski, Sophia . DSM-5 in Action 3rd Edition. SAM Ficher.

[3] Gilbert, Paul. Genes on the Couch (p. 181). Taylor and Francis.

[4] Leary, Mark. The Curse of the Self: Self-Awareness, Egotism, and the Quality of Human Life.

[5] Quartz, Steven. Cool (p. 134). Farrar, Straus and Giroux.

[6] Ronningstam, Elsa. Ph.D. Dimensional Conceptualization and Diagnosis of NPD.  Harvard University.

[7] Tracy, Jessica. The Self-Conscious Emotions . Guilford Publications.

[8] Treatment in Psychiatry.  Narcissistic Personality Disorder: Diagnostic and Clinical Challenges.  Eve Caligor, M.D., Kenneth N. Levy, Ph.D., Frank E. Yeomans, M.D., Ph.D.

Leave a Reply

Your email address will not be published. Required fields are marked *