Controversies in Narcissistic Personality Disorder Diagnosis

Introduction to Personality Disorders and DSM-5

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), personality disorders can be defined as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture" (National Institute of Mental Health – NIMH, 2017). Various personality disorders are recognized under the DSM-5, including — but not limited to — schizoid personality disorder, paranoid personality disorder, obsessive-compulsive personality disorder, narcissistic personality disorder, borderline personality disorder, avoidant personality disorder, and antisocial personality disorder. A significant number of individuals are at some point diagnosed with a personality disorder. Over time, various diagnostic mechanisms have been proposed and treatment approaches formulated. However, a range of controversial elements have emerged regarding both the diagnosis and treatment of personality disorders. This paper explores those issues, with a particular focus on narcissistic personality disorder.

Narcissistic personality disorder (NPD) is a condition in which a person holds an unrealistic and largely inflated perception of their own self-importance. There are those who argue that the diagnostic definitions of this particular disorder fail to capture the true nature and essence of the condition. For instance, according to Ronningstam (2016), the diagnostic meaning assigned to narcissistic personality disorder does not adequately focus on the internal and underlying struggles of the patient. Instead, Ronningstam argues that the definition is largely oriented toward attitudes and behaviors intended to secure clinicians' attention. As a consequence, Ronningstam (2016) further observes that the diagnosis of narcissistic personality disorder has taken on a less informative and more judgmental perspective.

Diagnostic Controversies in Narcissistic Personality Disorder

There are also those who argue that the diagnosis and treatment of the disorder fails to account for social context. According to Mason (2021), a wide range of factors can affect an individual's ability to relate to others and to cope with daily life. Two such factors, as Mason further notes, are the environment and the situation — social contexts that are largely overlooked in the diagnosis of narcissistic personality disorder.

Our understanding of personality disorders — and narcissistic personality disorder in particular — remains in a state of constant evolution. Despite the controversies highlighted above, there is little doubt that narcissistic personality disorder creates significant difficulties across multiple domains, including interpersonal relationships, financial affairs, and workplace relations (Mason, 2021). For this reason, it is important to continue deepening our understanding of the disorder, especially among populations that have not been traditionally studied.

One such gap concerns the diagnosis of narcissistic personality disorder in children. Some researchers argue that available literature does not sufficiently address how the disorder presents in younger populations (Drisko, 2020). This issue is further complicated by the fact that, as Drisko (2020) points out, "children are formally viewed by most diagnostic criteria as lacking consolidated personalities" (p. 139). There is therefore a pressing need to organize and consolidate the existing literature — and to guide future research — in this area.

Gaps in Understanding and Literature Incoherence

According to Miller, Lynam, Hyatt, and Campbell (2017), the literature relating to the diagnosis and treatment of narcissistic personality disorder is both incoherent and lacks cohesion. This is particularly evident, the authors argue, given that no systematic attempt has been made to draw a distinction "between grandiose (i.e., overtly immodest, self-centered, entitled, domineering) and vulnerable (e.g., self-centered, distrustful, neurotic, introverted) presentations of narcissism" (Miller, Lynam, Hyatt, & Campbell, 2017, p. 292).

There are a number of strategies that can be employed to maintain or sustain a therapeutic relationship with a client who has been diagnosed with narcissistic personality disorder. To begin with, it is essential to remain non-judgmental in all interactions. This means being aware of one's own biases and actively avoiding negative stereotypes. Secondly, all engagements with the client should remain professional and appropriate. In practice, this requires avoiding informal exchanges that could undermine the structure and integrity of the therapeutic relationship.

One of the central ethical and legal considerations in working with NPD clients is confidentiality. Confidentiality is essential for helping the client develop the level of trust necessary for a productive therapeutic engagement. It is also important for protecting the client from potential ridicule or adverse professional consequences should their condition be disclosed without consent. However, confidentiality is not without limits. For instance, if a client with narcissistic tendencies expresses a belief that their status or achievements are being undermined by another person and indicates an intention to harm that individual, disclosure to relevant third parties may be warranted.

There is also the matter of patient autonomy. A client may, within their rights, decline certain treatment strategies that are proposed. In such cases, the appropriate response is to actively engage the client to identify their concerns, and to seek to address any unfounded beliefs with evidence-based information rather than coercion or pressure.