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Controversial Issues in the Diagnosis of Narcissistic Personality Disorder: A Review of the Literature.

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 II 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 will 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:

1. The lack of a structured, coherent, theoretical foundation underlying its taxonomy (Brown, 2000; Clark, 1995; Faust & Miner, 1986; Follette & Houts, 1996)

2. The inconsistent use of psychometric theory and methodology, including reliability and validity issues (Blashfield & Livesley, 1991; Nelson-Gray, 1991; Steiner, Tebes, Sledge, & Walker, 1995)

3. 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)

4. 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.

Comorbidity

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).

Dimensional Models of Classification

Another major criticism of the Manual's classification system is the lack of a clearly delineated distinction between unique clinical conditions and arbitrary distinctions along dimensions of normal human functioning (Frances, First, & Pincus, 1995; Kendell, 1975). For example, the DSM-IV (1994) states of Axes II diagnoses "Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute Personality Disorders" (p. 630). However, nowhere in the diagnostic classifications or criteria are the operational definitions for any of these terms delineated or the thresholds for diagnosis clearly specified. At the heart of this debate is the notion of categorical versus dimensional models of classification (Blashfield & McElroy, 1995; Livesley et al, 1994).

Following the medical model tradition, the Manual's taxonomy is based on a categorical model. In categorical models, a diagnostic classification is present if the individual meets a predetermined number of criteria. For example, a person who meets five (or more) out of the nine criteria for narcissistic personality disorder is thought of as qualitatively different from a person who does not meet the criteria, and thus is diagnosed with the disorder. Failure to meet the specified criterion means the diagnosis is not present.

Dimensional models are based on a continuum of personality dimensions or traits. Different degrees of a diagnosis are present along the different dimensions of the continuum. For example, a person who meets four (or less) out of the nine criteria for narcissistic personality disorder is thought of as quantitatively different from a person who meets five (or more) of the criteria. While this individual is not diagnosed with the disorder, he or she is indeed placed on a dimension along the disorder's continuum and is thought of as possessing some of the disorder's traits. The theory behind this model contrasts sharply with that of the Manual and the medical model.

Some of the benefits of a categorical model of diagnosis include the simplification of the diagnostic process, its utility in making clinical decisions based on predetermined categories, and the simplification of research through its quantifiable nature. It is also the model that clinicians have been trained and are most familiar with. Nevertheless, the assumption that Axis I and Axis II disorders are qualitatively different from each other as well as the normal population has not been proven by the majority of the research. The aforementioned high comorbidity rates among Axis II diagnoses seem to indicate that individuals do not neatly fit any one diagnostic category but rather exhibit a range of characteristics that can easily fall in any given number of diagnostic categories.

Dimensional models have their origins in the early psychological studies of normal personality, such as those of Raymond Cattell (1965) and Hans Eysenck (1952). They have received increased attention in the literature given the inadequacies in categorical models of diagnoses brought up by recent studies addressing the issue of comorbidity. Cloninger (1987), Costa and McCrae (1990), Eysenck (1987), Kass, Skodol, Charles, Spitzer, and Williams (1985), and Livesley, Jackson, and Schroeder (1992) are among the authors that have proposed different dimensional models of the Manual's classification. Most models primarily differ on the name and characterization of the dimensions embedded in them.

Different dimensional models specific to narcissistic personality disorder have been proposed in the literature. Kernberg (1998) conceptualized narcissism in a continuum of severity ranging from normal to pathological. Other authors (Akhtar, 1989; Cooper & Ronningstam, 1992; Gabbard, 1989, 1994; Wink, 1991) have proposed different variations of a dimensional model that conceptualizes narcissistic personality into two different subtypes: overt and covert. The first type, which seems to be more consistent with the DSM-IV (1994) classification, refers to narcissistic individuals as oblivious, thick-skinned, egotistical, grandiose, arrogant, craving attention, and disregarding the feelings and reactions of others. The second type at the other end of the continuum refers to narcissistic individuals as hypervigilant, thin-skinned, dissociative, vulnerable, self-effacing, diverting attention, highly sensitive to the signals from others and easily hurt.

Millon and Davis (1996) stated that the DSM-IV Personality Disorders Work Group actually considered replacing the categorical model of diagnosis present in the DSM-III (1980) and DSM-III-R (1987) with a dimensional system in light of all the criticism that Axes II diagnoses had received. Widiger and Sanderson (1995) added that a proposal was made to include a dimensional model of diagnosis in the appendix of the DSM-IV (1994), and also argue for an implementation of this classification model in the upcoming fifth edition of the Manual. For a more thorough review of the categorical and dimensional model debate please refer to Clark (1999), Livesley et al. (1994), Maddux and Mundell (1999) and Widiger (1997).

The Importance of Culture

The Manual authors' oversight and apparent omission of the role that culture plays in psychological disorders and mental health constitute another major criticism levied against its taxonomic system (Aderibigbe & Pandurangi, 1995; Cervantes & Arroyo, 1995; Fabrega, 1987). In an interview for the American Psychological Association's The Monitor, Dolores Parron stated that the DSM-III-R (1987) contained "only two paragraphs dealing with ethnic and cultural issues" (DeAngelis, 1994, p. 36; see also Kleinman, 1996). Critics claim that this is primarily due to an ethnocentric approach based on an European American or Western model of psychology and mental illness (Fabrega, 1996; Gergen, Gulerce, Lock, & Misra, 1996; Lillard, 1998).

The authors of the DSM-IV (1994) attempted to address this long-standing criticism in two principal ways. First, the clinical presentations of the different disorders include a discussion narrative in the text specific to culture, age, and gender features. Second, a description of culture-bound syndromes not included in the Manual's classification was added near the end of the appendices. This appendix also includes an outline for cultural formulation to aid the clinician in assessing the impact of the client's cultural background.

Reactions to these actions from the American Psychiatric Association have been mixed. Some have lauded the acknowledgment of the role that culture plays in psychiatric diagnoses (DeAngelis, 1994). However, most writers have expressed a need for greater emphasis on culture in the classification of mental disorders (Kleinman, 1996; Thompson, 1996).

Alarcon and Foulks (1995) underscored the crucial nature of understanding the impact of culture in personality disorders. Kleinman (1988) and Littlewood (1990) argued that culture plays a greater role in personality disorders than in any other diagnostic category. The section on ethnic and cultural considerations of the DSM-IV's (1994) introduction reads "Applying Personality Disorder criteria across cultural settings may be especially difficult [italics added] because of the wide cultural variation in concepts of self, styles of communication, and coping mechanisms" (p. xxiv). Nevertheless, Alarcon, Foulks, and Vakkur (1998) reported that most reviews on personality disorders have not addressed the cultural domain.

The diagnosis of narcissistic personality disorder remains one of the most overlooked and ignored in terms of culture. Alarcon (1996) reviewed the history of the suggestions on personality disorders made by the Culture and Diagnosis Group to the American Psychiatric Association's Task Force in charge of monitoring revisions to be included in the DSM-IV (1994). He reported that the original proposal submitted for consideration included 219 words of cultural concepts specific to narcissistic personality disorder. This was surpassed only by the 250 words specific to paranoid personality disorder. The final number of cultural concept words published in the DSM-IV (1994) specific to narcissistic personality disorder was zero. This represented the lowest of any personality disorder, symbolizing a complete rejection of cultural considerations for the narcissistic personality disorder diagnosis.

This omission may be partly due to the lack of systematic studies exploring cultural variables specific to narcissistic personality disorder. While authors have consistently agreed on the importance of culture in the diagnosis (Alarcon et al., 1998; Foulks, 1996; Stone, 1998), a dearth in the empirical literature still remains. This shortage could be a result of different conceptualizations across countries and other cultures of what constitutes pathological versus normal narcissism--a direct result of the intricate link between narcissistic personality disorder and culture. For example, Smith (1990) reported that Asian American women have significantly lower narcissism scores than Caucasian American women, explained by cultural values of modesty, respect for authority, and collaboration as opposed to individualism and other traits consistent with a narcissistic personality. Martinez (1993) addressed the deliberately exaggerated sense of self (e.g., "flamboyance") present in some Mexican-American adolescents, which could be mistaken for narcissistic personality disorder traits.

Finally, Millon (1998) and Ronningstam (1999) pointed out that narcissistic personality disorder does not appear in the tenth revision of the International Statistical Classification of Diseases and Related Health Problems, (ICD-10; World Health Organization, 1992). The ICD-10 is the international equivalent of the Manual and consists of an official coding system and other related clinical research instruments and information. The American Psychiatric Association used the ICD as a model for the first Diagnostic and Statistical Manual of Mental Disorders, published in 1952. Ever since, the different revisions of the Manual have closely followed ICD taxonomy, such that both classification systems are compatible with each other.

The fact that narcissistic personality disorder is not in any of the ICD editions is significant. Millon (1998) and Ronningstam (1999) argue that this is partly due to the low prevalence of the disorder in some countries, and that it may not actually exist in others. The exclusion of narcissistic personality disorder as a diagnosis in other countries provides further evidence of its cultural entrenchment. This also serves as an example of the cultural nature of diagnoses included in the Manual. Since the Manual is published by the American Psychiatric Press, the narcissistic personality disorder construct can't help but be a product of the cultural society in which it is embedded.

TREATMENT IMPLICATIONS AND RECOMMENDATIONS

It should be evident by now that the narcissistic personality disorder diagnosis is mired in a lot of uncertainty and controversy. Clinicians should keep this in mind when incorporating the diagnosis into the treatment of their clients. With the following three recommendations, I attempt to stimulate critical, applied thought regarding some of the research results reported in this article. This should serve as a starting point for clinicians to further explore narcissistic and other personality disorders.

1. Given the high comorbidity reported in the literature, it is important to take a holistic approach to individuals who exhibit narcissistic personality traits. Individuals do not often seek treatment specifically for their narcissistic qualities, but rather for other conditions that may have been facilitated in part by these same qualities. As the disorder often coexists with other conditions, it is important to assess the extent to which narcissistic traits are impacting (e.g., interacting with, maintaining, escalating, etc.) other diagnoses and adjust treatment accordingly. Employing different assessment techniques and information gathering instruments will help achieve a clearer clinical picture.

For example, an individual who does not meet criteria for a narcissistic personality disorder diagnosis may seek treatment for help with depression. While the person may not manifest a sense of grandiosity or lack of empathy, an unfulfilled need for admiration may be escalating the depression. Thus, without a formal diagnosis, narcissistic personality traits are still playing a role clinically and must be addressed as such.

2. Considering the above recommendation, it may be important to incorporate dimensional models of classification when diagnosing and treating narcissistic individuals. A person may not manifest sufficient criteria to meet the diagnosis, yet there may be significant traits fostering or maintaining a coexisting condition. An informed clinician should build on the existing literature and conceptualize clients as exhibiting different traits along a narcissistic dimension.

For example, an individual may manifest a high sense of grandiosity, exaggerate accomplishments, be preoccupied with fantasies of unlimited power, and believe that she or he is unique from everybody around her or him. While these traits do not meet sufficient criteria for a diagnosis, the person will still act and present more consistent with somebody who has narcissistic personality disorder than somebody who does not. When developing a therapeutic alliance and goals for counseling, this must certainly need to be taken into account.

3. A substantial amount of literature suggests that narcissistic personality disorder is a culture-bound disorder. Therefore, clinicians must assess and diagnose individuals from different cultural backgrounds accordingly. Integrating cultural sensitivity and dimensional conceptualization may help the clinician better understand how a client's narcissistic trait fits with their background experience.

For example, an individual from a cultural background where collectivism and cooperation were encouraged may present for treatment distraught because of a need for success and admiration from others. They may exaggerate accomplishments and show arrogant attitudes. While they could certainly be exhibiting signs of a narcissistic personality disorder, they could also be struggling with acculturation issues and may be doing the best they can to fit in and be accepted by others around them.

The medical model espoused by the Manual encourages a remedial approach to treatment. Yet it is ironic to find among the descriptors for personality disorders the words enduring, pervasive, inflexible, and stable over time (DSM-IV, 1994, p. 629). It seems evident that this type of personality structure cannot be completely changed through several weeks of brief or closed-ended therapy. Perhaps it may be more fruitful to better understand personalities and personality disorders in order to more effectively treat other interacting concerns.

A final point regarding treatment of narcissistic personality disorder must be made. When the dichotomy espoused by categorical models of classification (e.g., disordered versus nondisordered) is eliminated, the traits associated with narcissistic personality disorder become more real. A clinician will probably be more likely to identify with somebody whom they see as different only in the degree to which they experience something as opposed to a "disordered" individual whom they differ in the way they experience things. Thus, it becomes very important for the clinician to conduct a self-assessment and know where they fall along each of the dimensions that they will be using to work with their clients. This is particularly the case in a disorder like narcissistic personality, where a clinician's need for success in the therapeutic relationship may interact with the client's need for success and accomplishment.

Working with an individual with a narcissistic personality disorder is therefore not only challenging therapeutically but also developmentally as a clinician and as a person. Given its psychoanalytic origins, transference and parallel process issues have thoroughly been addressed in the professional literature. For a more thorough review of these concerns please refer to Ivey (1995), and Schlutz and Glickauf-Hughes (1995).

CONCLUSION

Narcissistic personality disorder remains a controversial diagnosis. The high comorbidity with other mental disorders calls into question its validity as a diagnosis. Furthermore, its roots in psychoanalytic theory almost mandate the need for more systematic research to validate its applicability and usefulness as a "mental disorder" classification.

Some authors have also questioned the traits that merit this diagnosis. Is it not normal to fantasize unlimited success or power? Is it not normal to be envious of others? Is it not normal to lack empathy for some of the people you meet on a daily basis? Different models conceptualizing narcissism in a continuum of severity from normal to pathology have been proposed to address these and other related questions. Other authors have questioned the extent to which this diagnosis is merely a reflection of the individualistic, self-enhancement culture prevalent in many circles within the United States.

Perhaps these questions and concerns are all a reflection of the bigger picture: the intrinsic pitfalls in our system for classifying mental disorders. The Manual has become the standard in the field of mental health disorders, yet it is not without its flaws. While there is a time and a place for a taxonomy of mental disorders, and the Manual certainly provides a useful approach to this, it is important to pay close attention to and address some of the issues put forth and reviewed in this paper. For ultimately, the people that we interact with through our work are human beings first and diagnoses second--and this is what makes the valid study and reliable understanding of mental health concerns of paramount importance.

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Luis A. Rivas is a doctoral candidate, Department of Psychology, Southern Illinois University at Carbondale.
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