The publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980) marked the introduction of the multiaxial classification system for mental disorders. Axis H disorders, or "Personality disorders/Mental retardation," have since been part of the DSM--the definitive source in the classification of mental disorders. Among these diagnoses was Narcissistic Personality Disorder, a category that has prompted the concern of some and the criticism of others. The goal of this article is to review the literature on some of the issues that have been proposed as controversial with this diagnosis. These include: (1) the issue of comorbidity that questions the validity of the diagnosis, (2) the issue of dimensional models of classification and what constitutes a narcissistic personality disorder, and (3) the role that culture plays in the diagnosis. Treatment implications and recommendations based on the review follow.
The common term narcissism dates back to Greek mythology. The first written stories about the creation of the Greek hero Narcissus are said to have been written as Homeric hymns in the seventh or eighth century (Hamilton, 1942). Narcissism as a psychopathological construct has its origins in psychoanalytic theory. Although Ellis (1898) and Nacke (1899) first introduced the term to psychiatry, it was Freud (1914/1957) and Rank (1911) who utilized the concept to describe psychodynamic processes typified by excessive self-love and self-centeredness.
While Reich (1933/1972) and Horney (1937) later expanded on these ideas in their writings, theoretical advances on the concept remained stagnant until the works of Heinz Kohut and Otto Kernberg. In highlighting the importance of the developmental processes of the self in psychoanalytic theory, Kohut (1971,1977) is credited with popularizing the term narcissistic personality disorder through his continued work with the pathologically narcissistic population. Deeply rooted in Object Relations Theory, Kernberg's (1975) writings described narcissistic characteristics (e.g., self-love and aggrandizement) formed as a defense against a child's experience of extreme frustration in early object relationships.
The publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980) soon after Kohut's and Kernberg's work marked the official recognition of narcissistic personality disorder as a valid diagnosis. This was part of the distinction between Axis I and II disorders in the new multiaxial classification system. Along with the publication of this system came a new set of challenges for clinicians and researchers alike.
The purpose of this paper is to explore some of the issues that have been proposed as controversial with the diagnosis of Narcissistic Personality Disorder. It wilt begin with a brief overview of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) and some of its major criticisms. Narcissistic personality disorder will then be discussed in the context of other criticisms to the manual's taxonomy. These include: (1) the issue of comorbidity that questions the validity of the diagnosis, (2) the issue of dimensional models of classification and what constitutes a narcissistic personality disorder, and (3) the role that culture plays in the diagnosis. Finally, treatment implications and recommendations will follow.
Overview of Diagnostic and Statistical Manual of Mental Disorders
The DSM-IV (1994), published by the American Psychiatric Association, is considered by the mental health profession to be the definitive source in the classification of mental disorders (Barron, 1998). Given its origin and source of endorsement, it becomes readily apparent that the DSM-IV (1994) is inherently tied to the cultural system that engenders it. For example, it seems logical to assume that a diagnostic criterion endorsed by the American Psychiatric Association would be implicitly different from one endorsed by the European Psychiatric Association. However, the American Psychiatric Association has been able to avoid these comparisons, and the Manual has continued to be recognized as the definitive classification system for mental disorders.
Criticisms to the diagnostic classifications and criteria put forth by the American Psychiatric Association are well documented. They have come from a number of different sources and have addressed a number of different themes (Follette, 1996). Some of these criticisms include:
- The lack of a structured, coherent, theoretical foundation underlying its taxonomy (Brown, 2000; Clark, 1995; Faust & Miner, 1986; Follette & Houts, 1996)
- The inconsistent use of psychometric theory and methodology, including reliability and validity issues (Blashfield & Livesley, 1991; Nelson-Gray, 1991; Steiner, Tebes, Sledge, & Walker, 1995)
- The questionable applications of its different diagnoses to one gender relative to the other (e.g., sex bias; Gallant & Hamilton, 1988; Kaplan, 1983; Ross, Frances, & Widiger, 1995)
- The shift in focus across time from a clinically based biopsychosocial model to a research-based medical model (Fink, 1988; Rogler, 1997; Wilson, 1993).
Another major criticism against the Manual's classification system is the continuous proliferation of diagnoses and different categories for mental illness (Follette & Houts, 1996; Guze, 1995; Sarbin, 1997). Those who defend the growth of the Manual refer to this occurrence as evidence for scientific progress. Nevertheless, the validity of the new categories being proposed becomes suspect and warrants further research and empirical validation. Narcissistic personality disorder is one such category.
Narcissistic Personality Disorder
As has previously been stated, the publication of the DSM-III (1980) marked the introduction of narcissistic personality disorder as a valid diagnosis for a mental disorder. Although the diagnosis's primary theoreticians disagreed in its etiology, Kohut and Kernberg found agreement in the symptoms that typify narcissistic personality disorder. Its essential features include a pervasive sense of grandiosity, need for admiration, and a lack of empathy for the feelings of others (DSM-IV, 1994). For example, this could manifest itself behaviorally in the individual who exaggerates a minor achievement (e.g., cleaning the house), expects praise and recognition without doing anything to earn it (e.g., just for being alive), and feels entitled to express their opinion without being burdened by listening to that of others (e.g., "I don't care what you may have to say about this. Listen to what I have to say.")
As an independent diagnostic category, narcissistic personality disorder represents a single and discrete condition separate from any other mental disorder. Nevertheless, Richards (1994) has previously argued that nobody seems to conceptualize narcissistic personality disorder in exactly the same way. This seems to be a direct result of the notion of comorbidity, or a lack of distinction between different diagnostic criterion across Axes I and II disorders.
A major criticism levied against the Manual's classification system of mental disorders has centered on the seemingly arbitrary distinction between Axes I and II (Pfohl, 1999; Tyrer, 1995). Some see this as an unnecessary addition of mental disorders and question the need for this distinction (Livesley, Schroeder, Jackson, & Jang, 1994). Others have argued that Axis II is solely a social construction that has no place in mental health (Brown, 2000). Blashfield and Livesley (1999) recently argued that "No rationale was offered in the DSM-III for subdividing mental disorders into clinical syndromes and personality disorders, nor has one been offered in subsequent editions" (p. 11).
The high comorbidity rate among the different personality disorders has been of particular concern to researchers (Clark, 1992; Widiger et al., 1991). Comorbidity in the diagnosis of narcissistic personality disorder has continuously been a source of debate (Geiser & Lieberz, 2000; Hart & Hare, 1998; Ronningstam, 1998; Ronningstam & Gunderson, 1988; Siever & Davis, 1991). Morey and Jones (1998) referred to narcissistic personality disorder as "...one of the worst offenders on Axis II with respect to diagnostic overlap" (p. 362). They cited research that has found overlap as high as 53.1%, with histrionic personality disorder, and 46.9%, with borderline personality disorder (Morey, 1988).
In their review of data from 11 different studies on narcissistic personality disorder, Gunderson, Ronningstam, and Smith (1995) found that individuals who met criteria for narcissistic personality disorder through structured DSM-III (1980) or Diagnostic Statistical Manual for Mental Disorders (3rd ed. rev; American Psychiatric Association, 1987) assessments consistently met criteria for other Axis II disorders. The overlap for individuals with narcissistic personality disorder and other personality disorders was often in excess of 50%. The overlap between some Axis II disorders was still present when DSM-III-R (1987) criteria were used, ranging between 25% and 50%.
Of particular concern is the aforementioned relationship between narcissistic personality disorder and other Axis II diagnoses, as it puts in question the validity of the diagnosis. For example, Gunderson et al. (1995) reported a study of individuals with different personality disorders where 21% of the participants also met criteria for narcissistic personality disorder. An important point is that Kernberg's original research was based on a population with a primary diagnosis of borderline personality disorder (Kernberg, 1975). The DSM-III (1980) adopted much of its criteria for the original narcissistic personality disorder diagnosis from Kernberg's behavioral descriptions (Ronningstam, 1999). As such, the high comorbidity rate previously reported in the literature seems plausible.
Another important point relevant to this controversy is the notion that the narcissistic personality disorder diagnosis has a long history of theoretical development but a short past of empirical research and validation (Gunderson, Ronningstam, & Smith, 1991; Ronningstam, 1998). Fortunately, a significant by-product of the neo-Kraepelinian influence on the DSM-III (1980) has been the increased amount of research generated by the emphasis placed on behavioral descriptors in the classification of mental disorders (Cox & Taylor, 1999). Understanding of narcissism and its related characteristics has increased manifold in the past 10 years, and new theoretical conceptualizations are spawning increasingly complex research paradigms. For a more thorough review of recent research paradigms and theoretical advances please refer to Hilsenroth, Handler, and Blais (1996) and Morey and Jones (1998).
- Rivas, Luis A., Controversial Issues in the Diagnosis of Narcissistic Personality Disorder: A Review of the Literature; Journal of Mental Health Counseling; Jan 2001; Vol. 23, Issue 1.
Reflection Exercise #9
The preceding section contained information
about controversies regarding narcissism diagnosis. Write three case
study examples regarding how you might use the content of this section in your
What is a major concern regarding the diagnosis of narcissism? Record the letter of the correct answer the .