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Narcissistic Personality Disorder Has Been Medicalised

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I have been a consumer of mental health services for many diagnoses, including but not limited to narcissistic personality disorder (NPD). I got the diagnosis when I was in high school. I was young and awkward and wasn’t relating well with my peers. I did what I could, albeit self-defeating and self-centered, to try to make friends with my classmates. While not making a formal diagnosis, the hospital clinical staff said I exhibited narcissistic traits. 

Since adolescents should never be diagnosed with personality disorders, the diagnosis never stuck. Neither did my behaviors as I passed into other stages other development and early adulthood more gracefully and prosocial. 

Existing definitions of NPD offer insight into possible treatment pathways for people suffering from this condition. These pathways are often overlooked and never applied in the course of treatment. I suspect clinicians don’t move forward with selecting a treatment modality if the roadmap is rooted in meaning-making instead of disputing beliefs and behavior modification. However, for people seeking support and resources to battle this disorder, behavior changes, and therapeutic reframing, there is currently a lack of research and treatment or support for families impacted by the fallout of NPD behaviors in familial systems.

Medicalisation of ‘personality’ disorders

Pathology in NPD has been deeply associated with the DSM-5 Diagnostic Manual for Mental Disorders diagnostic criteria. I suggest there may be different available options to select viable treatment pathways for targeting problematic symptoms. Consumers, families, and caregivers continue to be disillusioned by the lack of progress patients make in therapy. After all, personality disorders are considered long-term, chronic, and entangled in the current clinical issues that locating real therapeutic inroads is simply beyond hope.

Alternative approaches

By way of their covert symptoms at work, people with NPD present a problem for clinicians by their misleading presentations making it hard to get an accurate clinical picture. Providing psychotherapy when symptoms become active is the previous gold standard for NPD. I am now suggesting a new approach. My approach doesn’t put too much value on treating the so-called symptoms of NPD. Instead, I believe that the true inroads to the therapeutic benefits of treatment are repurposing the patient’s negative behaviors. 

People don’t come in through the therapy office door for NPD. NPD can contribute to other diagnoses and psychosocial and psychological problems for patients to manage on their own without treatment. For example, typically, NPD patients present with depression or related anxiety because of various symptoms and unmet needs, which drive these patients into treatment.

Debunking assumptions

Based on this assumption, I would hazard to say that psychotherapy’s primary focus should not be symptom management. Treating the NPD symptom in isolation rejects the reason other deeper issues formed and manifested in the patient’s lifelong disorder. These may include, e.g., full-blown clinical Depression, Anxiety, and other affective state regulators, which become problematic to treat in tandem when NPD symptoms are active.

Re-inventing the wheel in psychotherapy gets old fast. Practitioners should begin to treat the underlying problems with their patients and not rely on crisis-driven, ancillary or straightforward behavior modification techniques in the treatment of people suffering from NPD. 

Real change is only possible when the same sophistication is applied in session by the therapist as any other disorder that is acute or not long-term. Learning this can do this in group therapy, which has proven to help clients gain the reflective lens necessary to cultivate personal insight into their interpersonal landscapes.

Except for ‘lacking empathy,’ most if not all of the so-called NPD indicators can be mobilized into strengths for consumers in NPD treatment. I will use the example of grandiosity and requiring excessive admiration from others to illustrate how the behavior can flip from a ‘deficit’ into strength and even an asset to the person carrying this label.

I can fully understand why people carrying this diagnosis are labeled. Let’s get underneath this misnomer. Patients with NPD, like everyone else, are mindful and articulate their needs as precisely as possible. I will make the point this behavior is less ‘grandiose,’ ‘needy,’ and ‘critical’ than many clinicians make it out to be in the context of NPD treatment. So, let’s use a hypothetical situation to tease this NPD misnomer. 

The role of empathy

When was the last time you were happy when a friend or family member didn’t meet your needs? Even easier to visualize, let us say you were at the airport and your baggage carrier mishandled your bags and dropped breakables on the floor. Did you respond by giving the airline a big tip? Probably not; you were likely upset when your property was damaged.

The difference between the NPD response to this hypothetical clumsy baggage carrier or friend is the extremeness or degree of distress when things don’t go as planned. I believe this behavioral display is more indicative of rigidity in thinking. But alas, flexibility is not on the grand list of NPD symptoms. 

Of course not, because these are not character-logical deficits and over ego indulgent thinking. Many people get very upset, often going far beyond appropriate, in the workplace or online for coffee without being labeled with this diagnosis. Instead, healthy people are critical and aware of their needs.

Teaching empathy might work to keep the NPD patient more organic ways of meeting their needs. I recommend therapists examine the benefits of kindness and have their patients strive to make genuine connections in their lives. Therapists need to explore the importance of holding space for other people and illustrate the benefits of having compassion for other people. 

People with NPD, despite their behavior, all want to relate with others more productively. If only to get what they want from their end of the relationship, people with NPD understand empathy as a hindrance, if not a weakness, when interacting with other people. 

Cultivating connections and emotional labour

People will be less inclined to feel envious of others when they can connect with people on a more authentic level. Active involvement in other people’s lives through emotional labor creates spaces for people with NPD to feel more connected with their world and less adversarial. 

When people with NPD make decisions about their welfare, it leaves room for greater exchange of ideas and less defensive behavioral stances. Instead of placing limitations in the course of therapy which gets very old fast for people in treatment, people with this diagnosis need to reach for the upper limits of their success and not what the DSM prognosis says will be their lot in life.

Max E. Guttman, LCSW  is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.


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