Three cases of narcissistic personality disorder through the lens of the DSM-5 alternative model for personality disorders.

Abstract

The DSM-5 Section III alternative model for personality disorders (AMPD) distinguishes general personality impairment from trait-based descriptions of personality disorder expression. The inclusion of the AMPD in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides a scaffold for classification and diagnosis of personality pathology that merits further efforts to improve upon its assessment framework. Recent empirical work focuses on evaluating the reliability and validity of the Level of Personality Functioning Scale and the Personality Inventory for the DSM-5, demonstrating the structural and predictive distinctiveness of measures of pathological personality traits and impairment, evaluating practitioner acceptance and clinical utility, and examining associations with other important outcomes. To complement the increased research on the AMPD, this article focuses on the relevance of distinguishing levels of personality functioning and pathological personality traits in clinical practice. We present three cases of patients exhibiting pathological narcissism that vary in terms of severity of general personality dysfunction and prominent pathological personality traits assessed through the DSM-5 AMPD. We demonstrate that the DSM-5 AMPD provides the clinician with diagnostic criteria that exhibit greater fidelity with the varied presentations of pathological narcissism seen in clinical practice. We conclude that the DSM-5 AMPD provides a useful framework for incorporating different clinical presentations of narcissistic grandiosity, as well as characteristics of narcissistic vulnerability into the diagnosis of narcissistic personality disorder. Finally, we suggest that the clinical relevance of pathological traits in psychotherapy differs as a function of severity of personality impairment.

Pathological Narcissism and Nonsuicidal Self-Injury

“…Individuals higher in pathological narcissism have high expectations for themselves and others, but also rely on others for self and emotional regulation (e.g., Pincus, 2013;Pincus, Roche, & Good, 2015). Thus, such individuals may be more likely to engage in NSSI behaviors in response to self-enhancement failures and the lack of needed recognition or admiration from others (Blasco-Fontecilla et al, 2010;Pincus, Dowgwillo, & Greenberg, 2016). Several distinct patterns emerged when specific NSSI behaviors were grouped under the two higher-order domains of repetitive NSSI and impulsive NSSI.…”

“…These findings underscore the importance of assessing the full range of manifestations of pathological narcissism and corroborate clinical conceptualizations of suicidality in narcissistically disturbed individuals as a process reflecting the interplay of grandiosity and vulnerability. For example, clinical observations show that patients with a combination of affect dysregulation and pathological narcissism may respond to interpersonal stress with unexpected, potentially deadly, self-destructive behaviors (Blasco-Fontecilla et al, 2010;García-Nieto et al, 2014;Pincus et al, 2014Pincus et al, , 2016. Such behaviors may be an effort to protect the self from negative affect (e.g., shame, rage) associated with loss, defeat, and narcissistic injury while simultaneously giving the narcissistic individual the feelings of invulnerability and mastery over his or her own life (Ronningstam & Malstberger, 1998;Stone, 1989).…”

Diagnosis, Classification, and Assessment of Narcissistic Personality Disorder Within the Framework of Object Relations Theory

“…The AMPD criteria for NPD are provided in Table 1. The AMPD criterion set for NPD covers a broader range of clinical presentations than is covered in Section II, and is more inclusive of vulnerable as well as grandiose presentations of the disorder (Pincus, Dowgillo, & Greenberg, 2016). Specifically, criterion A for NPD specifies that self-appraisal may be "inflated, deflated or vacillating between extremes" and that "emotion regulation mirrors fluctuations in self-esteem."…”

A framework for treating DSM‐5 alternative model for personality disorder features

“…Perceived clinical utility is among the chief reasons for the persistence of the categorical model in the DSM . A number of case examples are now available in the literature for using the AMPD to develop treatment plans, and practice reviews generally suggest acceptability among clinicians . However, a framework for connecting AMPD features to specific therapeutic techniques is currently unavailable.…”