Revised Criteria for Narcissistic Personality Disorder
(designed by me, open to thoughts and commentary. this isn't an official revision, seeing as I'm not a contributor to the DSM. rather, the intent is to clarify the wording and produce a version that is less subjective and ambiguous.)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of maladaptive traits. To diagnose narcissistic personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.
b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
2. Impairments in interpersonal functioning (a or b):
a. 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.
b. Intimacy: A sense of detachment in relationships; higher levels of emotional withdrawal associated with larger degrees of closeness; a tendency to focus on all aspects of the relationship except for the feelings and experiences of the other, unless perceived as relevant to self
B. Maladaptive traits characterized by an attempt to protect oneself from potential criticism, and from mistreatment or general life dissatisfaction associated with criticism, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Grandiose sense of self (e.g., believes that they are inherently more powerful or capable than others in some way and may place an enormous pressure on themself to measure up to this self-image, believes that they are uniquely bad or inferior in some way, may struggle with paranoia due to an over-estimation of effect on others)
2. Attempt to regulate emotions and self-esteem through fantasies of unlimited success, power, brilliance, beauty, or ideal love, while avoiding real-life situations that conflict with this internal narrative
3. Association with or avoidance of people, groups, or institutions based upon an attempt to gain admiration or avoid criticism
4. Seeks out admiration in an attempt to regulate mood; may struggle with self-destructive behaviors (i.e., isolation, impulsivity, self-punishment, overexertion, etc.), intensely unpleasant emotions, or lack of motivation when they don't feel admired
5. An expectation of automatic agreement or compliance associated with feelings of security, i.e., an expectation that others will automatically agree or comply with them followed by confusion or distress if these expectations are unmet, attempts to attain closeness with others via agreeing and complying with everything the other person wants, or attempts to get the other person to agree and comply with everything they want
6. Periods of intense boredom or dissatisfaction resulting from a lack of connection with others; an attempt to regulate these emotions through material pursuits, personal gain, or self-destructive behaviors
7. May miss social cues or struggle with self-awareness due to a lack of empathy or a preoccupation with their self-image
8. Frequent comparisons to others, often followed by bitterness towards self or others for perceived differences in likability
9. Difficulties in emotional and behavioral regulation in response to perceived criticism or slights, as characterized by one (or more) of the following:
Fight response (e.g., intense anger towards self or others, self-punishment, hostility, destructive behavior)
Flight response (e.g., isolation, avoidance of the source of perceived criticism, frantic attempts to distract self)
Freeze response (e.g., brain fog, dissociation, major drops in motivation, not addressing or resolving the situation)
Fawn response (e.g., over-apologizing, heavily internalizing the perceived criticism, preoccupation with seeking approval or assurance)
C. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
1: Re-wrote the section for intimacy in 2B. Its original wording didn't address the actual problem present within the disorder, and instead focused on how others might perceive the symptom.
In people who have a history of trauma or who were otherwise denied the opportunity to form safe and healthy connections with others, it's a natural defense mechanism to fixate on oneself within a relationship:
Preoccupation with how they're perceived by the other person (Subconscious conditioning: Are they about to hurt me for something they dislike about me? If so, how can I change myself or their viewpoint of me to protect myself?)
Positive feelings, and feelings of closeness, prompted by feeling adored (Subconscious conditioning: We're all born with the need for human connection, but when we grow up being abused and neglected when caregivers dislike something about us, the only times we're safe to feel positive and close feelings with another person are when it's clear that they're happy with us)
Opportunity for personal gain potentially being one of the biggest factors in deciding whether or not to enter or remain in a relationship (Subconscious conditioning: If an unsafe caregiver isn't providing necessities or something that will help with self-soothing or happiness, then there's no point risking one's safety by interacting with them more than necessary)
Detachment from the other person (Subconscious conditioning: caring about* and having a personal interest in other people turned out to be exceedingly painful and potentially dangerous, and may have been used against us)
*I am not saying that detachment necessarily means not caring about the other person- just that we may be more prone to emotionally detaching or not being as preoccupied with the experiences of the other person.
In every relationship, there is a focus on the self, a focus on the other person, and a focus on the experiences that come with the relationship. The lack of focus on the other person doesn't mean that the other two focuses are abnormal or shouldn't exist; it simply means that someone may struggle with mutuality, usually due to past experiences with trauma. While this obviously can put a strain on relationships, it does not mean that someone is intentionally being exploitative, that they only care about the other person's well-being as long as they're benefiting them in some way, or even that they don't desire a genuinely close relationship with someone.
2: Rewrote the entire B section, and re-introduced elements from the DSM-IV. The B section in the DSM-V had a lot of subjective and ambiguous parts, and lacked focus on the actual issue and the various ways that issue could present. I also changed the wording from "pathological personality traits" to "maladaptive traits".
3: Changed or rewrote symptoms listed in section B to be less subjective and to place the emphasis on how the disorder affects the person who has it, as opposed to how others may perceive the symptoms. I also expanded it somewhat to include variations in how the root issue may present.
