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DSM-III

Diagnostic Criteria

The following are characteristic of the individual's current and long-term functioning, are not limited to episodes of illness, and cause either significant impairment in social or occupational functioning or subjective distress:

A. Grandiose sense of self-importance or uniqueness, e.g., exaggeration of achievements and talents, focus on the special nature of one's problems.

B. Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

C. Exhibitionism: the person requires constant attention and admiration.

D. Cool indifference or marked feelings of rage, inferiority, shame, humiliation, or emptiness in response to criticism, indifference of others, or defeat.

E. At least two of the following characteristic of disturbances in interpersonal relationships:

  1. entitlement: expectation of special favors without assuming reciprocal responsibilities, e.g., surprise and anger that people will not do what is wanted
  2. interpersonal exploitativeness: taking advantage of others to indulge own desires or for self-aggrandizement; disrergard for the personal integrity and rights of others
  3. relationships that characteristically alternate between the extremes of overidealization and devaluation
  4. lack of empathy: inability to recognize how others feel, e.g., unable to appreciate the distress of someone who is seriously ill.

Differential Diagnosis

Borderline and Histrionic Personality Disorders are often also present; in such instances, multiple diagnoses should be given.

DSM-IV

Diagnostic Criteria

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early childhood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
  2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  3. believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
  4. requires excessive admiration
  5. has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
  6. is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
  7. lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
  8. is often envious of others or believes that others are envious of him or her
  9. shows arrogant, haughty behaviors or attitudes

Differential Diagnosis

Other Personality Disorders

Other Personality Disorders may be confused with Narcissistic Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Narcissistic Personality Disorder, all can be diagnosed.

Histrionic, Antisocial, and Borderline Personality Disorders

The most useful feature in discriminating Narcissistic Personality Disorder from Histrionic, Antisocial, and Borderline Personality Disorders, whose interactive styles are respectively coquettish, callous, and needy, is the grandiosity characteristic of Narcissistic Personality Disorder. The relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns also help distinguish Narcissistic Personality Disorder from Borderline Personality Disorder. Excessive pride in achievements, a relative lack of emotional display, and disdain for others' sensitivities help distinguish Narcissistic Personality Disorder from Histrionic Personality Disorder. Although individuals with Borderline, Histrionic, and Narcissistic Personality Disorder may require much attention, those with Narcissistic Personality Disorder specifically need that attention to be admiring. Individuals with Antisocial and Narcissistic Personality Disorders will share a tendency to be tough-minded, glib, superficial, exploitative, and unempathetic. However, Narcissistic Personality Disorder does not necessarily include characteristics of impulsivity, aggression, and deceit. In addition, individuals with Antisocial Personality Disorder may not be as needy of the admiration and envy of others, and persons with Narcissistic Personality Disorder usually lack the history of Conduct Disorder in childhood or criminal behavior in adulthood.

Obsessive-Compulsive Personality Disorder

In both Narcissistic Personality Disorder and Obsessive-Compulsive Personality Disorder, the individual may profess a commitment to perfectionism and believe that others cannot do things as well. In contrast to the accompanying self-criticism of those with Obsessive-Compulsive Personality Disorder, individuals with Narcissistic Personality Disorder are more likely to believe that they have achieved perfection.

Schizotypal and Paranoid Personality Disorder

Suspiciousness and social withdrawal usually distinguish those with Schizotypal or Paranoid Personality Disorder from those with Narcissistic Personality Disorder. When these qualities are present in individuals with Narcissistic Personality Disorder, they derive primarily from fears of having imperfections or flaws revealed.

Manic and Hypomanic Episodes

Grandiosity may emerge as part of Manic or Hypomanic Episodes, but the association with mood change or functional impairments helps distinguish these episodes from Narcissistic Personality Disorder.

Personality Change Due to a General Medical Condition and symptoms related to substance use

Narcissistic Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).

Normal personality traits

Many highly successful individuals display personality traits that might be considered narcissistic. Only when thees traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute Narcissistic Personality Disorder.

 DSM-5

Diagnostic Criteria

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or autonomic compliance with his or her expectations).
  6. Is interpersonally exploitative (i.e., takes advantag of others to achieve his or her own ends).
  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviors or attitudes.

Alternative Model

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

  1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotion regulation mirrors fluctuations in self-esteem.
  2. Self-direction: Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivation.
  3. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
  4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others' experiences and predominance of a need for personal gain.

B. Both of the following pathological personality traits:

  1. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others.
  2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

C. The impairments in personality functioning and the individual's personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations.

D. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood.

E. The impairments in personality functioning and the individual's personality trait expression are not better explained by another mental disorder.

F. The impairments in personality functioning and the individual's personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma).

G. The impairments in personality functioning and the individual's personality trait expression are not better understood as normal for an individual's developmental stage or sociocultural environment.

Specifiers

Trait and personality functioning specifiers may be used to record additional personality features that may be present in narcissistic personality disorder but are not required for the diagnosis. For example, other traits of Antagonism (e.g., manipulativeness, deceitfulness, callousness) are not diagnostic criteria for narcissistic personality disorder (see Criterion B) but can be specified when more pervasive antagonistic features (e.g., "malignant narcissism") are present. Other traits of Negative Affectivity (e.g., depressivity, anxiousness) can be specified to record more "vulnerable" presentations. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of narcissistic personality disorder (Criterion A), the level of personality functioning can also be specified.

Differential Diagnosis

Other personality disorders

Other personality disorders may be confused with narcissistic personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to narcissistic personality disorder, all can be diagnosed.

Histrionic, antisocial, and borderline personality disorders

The most useful feature in discriminating narcissistic personality disorder from histrionic, antisocial, and borderline personality disorders, in which the interactive styles are coquettish, callous, and needy, respectively, is the grandiosity characteristic of narcissistic personality disorder. The relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns also help distinguish narcissistic personality disorder from borderline personality disorder. Excessive pride in achievements, a relative lack of emotional display, and disdain for others' sensitivities help distinguish narcissistic personality disorder from histrionic personality disorder. Although individuals with borderline, histrionic, and narcissistic personality disorders may require much attention, those with narcissistic personality disorder specifically need that attention to be admiring. Individuals with antisocial and narcissistic personality disorders share a tendency to be tough-minded, glib, superficial, exploitative, and unempathetic. However, narcissistic personality disorder does not necessarily include characteristics of impulsivity, aggression, and deceit. In addition, individuals with antisocial personality disorder may not be as needy of the admiration and envy of others, and persons with narcissistic personality disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood.

Obsessive-compulsive personality disorder

In both narcissistic personality disorder and obsessive-compulsive personality disorder, the individual may profess a commitment to perfectionism and believe that others cannot do things as well. In contrast to the accompanying self-criticism of those with obsessive-compulsive personality disorder, individuals with narcissistic personality disorder are more likely to believe that they have achieved perfection.

Schizotypal and paranoid personality disorder

Suspiciousness and social withdrawal usually distinguish those with schizotypal or paranoid personality disorder from those with narcissistic personality disorder. When these qualities are present in individuals with narcissistic personality disorder, they derive primarily from fears of having imperfections of flaws revealed.

Other personality traits

Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute narcissistic personality disorder.

Mania or hypomania

Grandiosity may emerge as part of manic or hypomanic episodes, but the association with mood change or functional impairments helps distinguish these episodes from narcissistic personality disorder.

Substance use disorders

Narcissistic personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.