The challenge of understanding and treating narcissistic personality disorder has been compounded by the multiple, wide-ranging, and often ambiguous meanings of the terms narcissism and narcissistic pathology. As Cooper has written, “The fuzziness of the term reflects the complexity of the concepts, while the persistence of the term reflects their central importance”. At the same time, he continues, “[W]e remain with more ambiguity than is desirable or useful”.

The history of the concept of narcissism has been reviewed elsewhere. Recent literature recognizes that narcissism is a healthy, normal, and necessary component of psychological development and psychic life, thereby avoiding the pejorative connotation that the term narcissistic has often assumed. Narcissistic traits, moreover, appear in all forms of character pathology. A constellation of certain pathological traits that dominate the life history and the transference relationship distinguishes narcissistic personality disorder from other forms of personality disturbance.

Narcissistic pathology assumes a wide range of clinical and functional forms. Clinically, these forms range from the arrogant, boastful individual who steals the spotlight to the shy, easily slighted person who avoids center stage. Functionally, they may range from the prominent businessperson and political leader to the malignant narcissist and premeditating murderer.

Three overlapping systems have evolved for diagnosing narcissistic personality disorder, differentiating it from other character pathology, and capturing the diversity of its clinical presentation. Narcissistic personality disorder can be diagnosed 1) according to DSM criteria; 2) according to a pattern of intrapsychic affects, defenses, and object relationships; and 3) according to the forms of transference that develop in therapy. Clearly, the linear model of first formulating a diagnosis and then planning and implementing a treatment cannot always be followed with patients with narcissistic personality disorder because the diagnosis may become apparent only after a period of psychotherapy or an extended evaluation.

DSM Description
The DSM-IV criteria for narcissistic personality disorder (

Table 85-1) are intended to correspond more closely to accepted clinical use and to better distinguish narcissistic personality disorder from other Axis II diagnoses than did the DSM-III-R (American Psychiatric Association 1987) criteria. The DSM-IV criteria differ from the earlier criteria in several respects. “Need for admiration” has been included, along with grandiosity and lack of empathy, as one of the three core features of the disorder, replacing the earlier DSM-III-R “hypersensitivity to the evaluation of others.” The triad of grandiosity, lack of empathic connection to others, and craving for admiration represents a consensus among clinicians and researchers regarding the core features of narcissistic personality disorder. These features, however, may be more or less manifest and more or less conscious. Grandiosity may hide behind false modesty, lack of empathy may hide behind a veneer of concern for others, and need for admiration may become evident only in the seemingly self-sufficient individual’s collapse when the admiration is withdrawn. Extended and sophisticated interviewing may be required for accurate diagnosis.

Criterion 1 in DSM-III-R, “Reacts to criticism with feelings of rage, shame, or humiliation (even if not expressed),” has been eliminated as too nonspecific in differentiating narcissistic personality disorder from paranoid and borderline personality disorders. A behaviorally observable criterion, “arrogant, haughty behaviors or attitudes” (DSM-IV, criterion 9), has been added in its place to capture directly the disdain and contempt toward others that are frequently observed in individuals with pathological narcissism. Gunderson et al. also found that this criterion “helpfully differentiates narcissists from histrionics, antisocials, and borderlines who are, respectively, self-centered but coquettish, distant but callous, and entitled but needy”. (Indeed, as we discuss later, we have found the narcissistic patient’s contempt to be a clinically useful point of entry in treatment, because contempt is often both ego-syntonic and ego-dystonic for such patients.)

Two other DSM-III-R criteria were modified. The manifest pursuit of attention, “e.g., keeps fishing for compliments,” was eliminated in DSM-IV because it implies more overt insecurity than is typical of many narcissistic individuals. In addition, the preoccupation with feelings of envy (criterion 9 in DSM-III-R) was qualified to include the tendency of some narcissistic individuals to infer envy of themselves by others rather than to experience their own envy directly. It is important for the therapist to recognize that induction of envy in others - including in the therapist - is a narcissistic defense that frequently will enter into the transference-countertransference relationship and can be understood as the patient’s effort to ward off his or her own envy of the therapist and the concomitant feelings of deep personal inadequacy.

Although the DSM-IV description of narcissistic personality disorder approaches the more inclusive picture of the narcissistic character found in the clinical literature, a gap between the two remains. Indeed, the DSM-IV criteria continue to stress the manifest grandiosity and exhibitionism of the overt, noisy, or oblivious narcissistic individual - arrogant, aggressive, self-absorbed, unempathic, hogging the spotlight - and fail to capture the other pole of the narcissistic spectrum - the shy, embarrassed, covert, or hypervigilant narcissistic individual. At this end of the narcissistic continuum, the individual, ashamed of his or her wishes for grandiose self-exhibition - of which he or she may be unconscious - presents as highly sensitive to the reactions of others, inhibited to the point of self-effacement, easily humiliated, on the lookout for personal slights, and shunning of attention. The existence of these two subtypes of narcissistic personality disorder has received further support in empirical studies in which the distinction was found to be statistically significant.