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Dimensional Models of Classification
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 authors of the DSM-IV (1994) attempted to address this longstanding 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
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).
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.
Reflection Exercise #10