What is a Pathological Disorder?
Love seeketh only Self to please,
To bind another to its delight,
Joys in another’s loss of ease,
And builds a Hell in Heaven’s despite.
— William Blake from “The Clod and the Pebble”
Though Blake showed an intuition of the evils of pathological narcissism in the quoted verses, there are certain personality disorders that are easier to spot for the non-professional, because they dramatically hinder the normal functioning of individuals in society. While common people tend to be able to spot a common and identifiable disorder like major depression, which may prevent individuals from going to work and going out, for example, they rarely put a name on certain types of NPD, often dismissing it as just a “big ego” problem.
In fact, narcissists can be huge performers in their professional field, because their inflated sense of self-importance drives them on, to show the world just how important they really are. As society commonly associates personality disorders and psychiatric conditions with the inability to perform and function normally, these high performers may remain undiagnosed for years, and sometimes even for their whole lives. The fact that the scientific community has devoted comparatively little attention to NPD, as opposed to other personality disorders, further boasts its underdiagnosis.
The problem of diagnosis
The bulk of the literature dedicated to narcissistic personality disorders over the last decade has largely focussed on the need to establish new and improved diagnosis models:
The attention to the narcissistic individual’s external, symptomatic, or social interpersonal patterns — at the expense of his or her internal complexity and individual suffering — has also added to the diagnosis’ low clinical utility and limited guidance for treatment. Recent studies and reviews have pointed to the need for change in the diagnostic approach to and formulation of narcissism.
Let’s take a look at the standard diagnosis criteria of NPD, as set forth by the DSM-IV-TR, which defines NPD as:
… an all-pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration or adulation and lack of empathy, usually beginning by early adulthood and present in various contexts.
According to this diagnostic manual, NPD is present when at least five of the following criteria are met:
- has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
- is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
- 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)
- requires excessive admiration
- has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
- is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
- lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
- is often envious of others or believes that others are envious of him or her
- shows arrogant, haughty behaviors or attitudes
Now, with just a quick glance at this list, I am sure each one of my readers can think of at least a handful of people they know, who seem to meet many of these criteria. Not all of them must, of course, necessarily be suffering from pathological NPD, though some of them might be, and they might remain undiagnosed, due to the fact that the line between pathological and healthy narcissism is an extremely blurry one.
Ronnie Solan dedicated much of her work to attempting to establish these boundaries:
The process of narcissistic self-love is activated by three absolute narcissistic needs: (a) to experience an affective state of well-being (homeostasis) in the familiar and constant state of self-love; (b) to separate the familiar self from the unfamiliar non-self; and (c) to integrate or befriend the unfa- miliar yet “similar enough” non-self within the self in order to contain over-excitation.
Within a healthy narcissistic structure, these absolute needs must reach a state of equilibrium, which means that deciphering the familiar and befriending the unfamiliar (non-self) must be coherent and integral with the genuine identities of familiar self-codes. However, if one of these needs is incoherently regulated in relation to the others, the threat of narcissistic imbalance emerges, further imperiling the integrity of the self-codes.
What Solan calls the “narcissistic imbalance” can appear very elusive to the naked eye of the non-professional observer. The pathological narcissist, with his/her lack of empathy and sense of self-importance will be the last to acknowledge that he/she has a problem. Therefore, the call for help that might bring in a therapist capable of identifying and treating NPD may never come, especially if the individual in question is a high performer, which society tends to view as a sign of personal success.
Expanding the NPD concept
If scholars and clinicians can’t agree on diagnosis criteria, it will be no surprise to find that the general assumptions of society about what constitutes NPD will be rather uncertain. Regarding this issue, a study published in 2008 found certain core features of the disorder which are not included in the DSM-IV’s description of it. These were: interpersonal vulnerability and underlying emotional distress, anger, difficulty in regulating affect, and interpersonal competitiveness.