Criteria for diagnosing NPD

As promised from last week's blog, here is a more in-depth look at the diagnostic criteria for Narcissistic Personality Disorder (NPD). I have included both the most recent criteria from the Diagnostic and Statistical Manual of Mental Disorders Fourth edition and Fifth Edition from the American Psychiatric Association for reference as completeness. The 5th Edition was published in 2013 and seems to be a bit more difficult to follow and so I though including the 4th Edition will help with overall understanding because it seems to me a bit more straight forward.


DSM-4
A pervasive pattern of grandiosity(in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(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, or 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) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(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 or attitudes

DSM-5 

A. Significant impairments in personality functioning manifested by:

1. Impairments in self functioning (a or b):

a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.

b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.

AND

2. Impairments in interpersonal functioning (a or b):

a. 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.

b. 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. Pathological personality traits in the following domain:

1. Antagonism, characterized by:

a. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.

b. Attention Seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

C. The impairments in personality functioning and the individual's personality trait expression are relatively stable :across time and consistent across situations.
D. The impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

Lake Tahoe

Introduction

I am the daughter of a narcissistic personality disordered (NPD) mother and an enabling father. I am also a practicing physician, wife, mother, landlord and writer.  Having an NPD mother is really something that I have only recently realized after a particularly crazy making encounter with my mother a few years ago. I was on the phone with a friend describing this horrible encounter where my mother out of the blue and with no evidence to to support her, claimed my husband was abusing our son. 

After much discussion with my friend, a fellow physician, he encouraged me to "Dust off your psychiatry books and re-read the Cluster B personality disorders. I think your mother may have one."

I was shocked at his suggestion. I had always suspected an underlying depression or anxiety but never a cluster B personality disorder. But out of desperation to find answers to her strange behavior and accusations I "dusted off" my old psychiatry books and reread the Diagnostic and Statistical Manual of Mental Disorders, 4th. Edition (DSM-IV) published by the American Psychiatric Association (www.psychiatry.org) criteria for cluster B personality disorders. The American Psychiatric Association  (APA) has since printed a 5th edition published in 2013 that places personalities disorders in the same category as other mental illness rather than its own axis as in DSM IV. The APA defines personality disorders as a "class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability."

The following is a list of the Cluster B personality disorders which are known as the dramatic, emotional or erratic disorders:

• Antisocial personality disorder: a pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behavior.
• Borderline personality disorder: pervasive pattern of instability in relationships, self-image, identity, behavior and affects often leading to self-harm and impulsivity.
• Histrionic personality disorder: pervasive pattern of attention-seeking behavior and excessive emotions.
• Narcissistic Personality Disorder: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy.

I write this blog in the hope that my stories of my past and present struggles and how I have worked and continue to work to overcome them can help people suffering from the same issues to heal and lead happy lives.

I will note that in order to maintain the privacy of my family and friends, I have changed names and in some cases details though the content will remain the same. 

Up next will be more detailed diagnostic criteria for NPD

Kona