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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
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:
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 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.
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).
Reflection Exercise #9