Identifying
Criteria
for Narcissistic
Elsa Ronningstam,
Ph.D.,
The authors report an exploratory effort to identify useful criteria for narcissistic personality disorder. They used the semistructured Diagnostic Interview for Narcissism others on
narcissism.
to assess 24 33 characteristics
The
narcissistic imputed
following
cantly sistic
more common among personality disorder:
sense
of uniqueness,
patients and to pathological
characteristics the patients a sense of
exaggeration
were
58
signifi-
with narcissuperiority, a
of talents,
boastful
and pretentious behavior, grandiose fantasies, seif-centered and self-referential behavior, need for attention and admiration, arrogant and haughty behavior, and high achievement. The results provide an empirical ba-
sis for developing cissistic (Am
personality J Psychiatry
an improved
set of criteria
for nar-
disorder. 1990; 147:918-922)
A
n empirical database was used in establishing some of the DSM-III and DSM-III-R axis II categonies, such as the antisocial, borderline, and schizotypat personality disorders. For many other categories, however, few on no empirical studies were available to inform the selection of criteria. This was true for nancissistic personality disorder (1-3), and the criteria delineating this diagnostic category have not yet been empirically evaluated. Our goat is to establish whether a discrete group of characteristics can reflect the clinical use of the nancissistic personality disorder diagnosis, and, if so, what relation these characteristics have to the set of DSMIII-R criteria. To do this we have developed a semistructured interview to assess the characteristics imputed to pathological narcissism in the literature and in our own clinical experience (4-6). In a prior report (7) we examined narcissistic traits in psychiatric patients. The present exploratory study investigated patients given the diagnosis of narcissistic personality disorder.
Received April 21, 1989; revisions received Oct. 26 and Dec. 6, 1989; accepted Jan. 1 1, 1990. From the Psychosocial Research Program, McLean Hospital. Address reprint requests to Dr. Gunderson, McLean Hospital, 1 15 Mill St., Belmont, MA 02178. Supported in part by grants from the Swedish Institute and Wallenberg Jubilee Foundation, Stockholm, and from the Psychosocial Research Program, McLean Hospital. The authors thank Ren#{233}Roy, M.D., and David Clinton, M.Appl.Sc., for their assistance. Copyright © 1990 American Psychiatric Association.
918
and John
Personality
Gunderson,
Disorder
M.D.
Most conceptually and descriptively difficult questions about the differential diagnosis of narcissistic personality involve borderline and antisocial personalities (8-14). In order to ascertain the best and most clinically useful criteria for narcissistic personality disorder, we chose a comparison group that included both patients with these “near-neighbor” conditions and patients with nonrelated psychiatric disturbances. We discuss the results from this study with respect to their implications for existing clinical and conceptual descriptions of pathological narcissism and for the DSM criteria.
METHOD The subjects of the study were 82 patients who gave written informed consent and met the selection cnitena: 1) they were 17-45 years of age, 2) they were capable of participating in a diagnostic interview, 3) they had no known organic impairment, and 4) they had official clinical diagnoses in any of the following categories. 1. Narcissistic personality disorder (N=24). To obtam narcissistic personality disorder patients who represented a reasonably prototypic sample, otherwise suitable patients were excluded if they had complicating axis I diagnoses, e.g., major psychosis on concurrent substance abuse. 2. Other “dramatic” cluster personality disorders, namely, borderline and antisocial (N=36). These diagnoses were confirmed by standardized interviews: the Diagnostic Interview for Borderline Patients (15) for the former and the Structured Clinical Interview for DSM-III-R Personality Disorders (16) for the tatter. Both interviews were conducted by trained, reliable interviewers. 3. Other psychiatric diagnoses (excluding the dnamatic cluster type of personality disorder) (N22). These diagnoses included (axis I) major depression (N 7), bipolar disorder (N=4), dysthymia (N= 1), schizophrenia (N=3), schizoaffective disorder (N 1), adjustment disorder (N=2), anorexia nenvosa (N= 1), and (axis II) mixed, atypical, and “anxious” cluster personality disorders (N=3). The official clinical diagnoses were established after 4-8 weeks of observation and were based on input from multiple sources. For inpatients the input was from administrative psychiatrists, psychotherapists, nuns-
Am
J
Psychiatry
1 47: 7, July
1990
ELSA
ing staff, and psychological and neurological testing. For outpatients the period of observation was usually much longer, and for them also, confirmatory second clinical diagnostic assessment by another professional was required for inclusion in our samples. This approach follows the “LEAD” (Longitudinal/Expert/Alt Data) standard (17). We had learned from previous studies (7, 18) that an adequate sample of patients with diagnoses of narcissistic personality disorder on antisocial personality disorder was not readily obtained from the accessible clinical services at our hospital. This was confirmed when we initiated this project by interviewing 45 suitable and consenting patients from the hospital’s inpatient and outpatient services. An additional 19 patients were then recruited by sending a memo to hospital staff members that specifically encouraged them to screen their practices for suitable patients and to gain permission for us to approach them. We also recruited 18 English-speaking patients from a correctional treatment institution who had had extensive psychiatric evaluations. Each subject was given the Diagnostic Interview for Narcissism (5, 6), which consists of 33 statements about characteristics, nine of which overlap with those in DSM-III-R. These statements are grouped into five sections: 1) grandiosity, 2) interpersonal relations, 3) neactiveness, 4) mood states, and 5) social/moral adaptation. The internal consistency for the entire interview is good (atpha=0.81), and the intenraten reliability is also acceptable for the statements (mean weighted kappa=0.68), the section scores (intractass R0.740.96, N= 18, p
Criteria
for Narcissistic
Elsa Ronningstam,
Ph.D.,
The authors report an exploratory effort to identify useful criteria for narcissistic personality disorder. They used the semistructured Diagnostic Interview for Narcissism others on
narcissism.
to assess 24 33 characteristics
The
narcissistic imputed
following
cantly sistic
more common among personality disorder:
sense
of uniqueness,
patients and to pathological
characteristics the patients a sense of
exaggeration
were
58
signifi-
with narcissuperiority, a
of talents,
boastful
and pretentious behavior, grandiose fantasies, seif-centered and self-referential behavior, need for attention and admiration, arrogant and haughty behavior, and high achievement. The results provide an empirical ba-
sis for developing cissistic (Am
personality J Psychiatry
an improved
set of criteria
for nar-
disorder. 1990; 147:918-922)
A
n empirical database was used in establishing some of the DSM-III and DSM-III-R axis II categonies, such as the antisocial, borderline, and schizotypat personality disorders. For many other categories, however, few on no empirical studies were available to inform the selection of criteria. This was true for nancissistic personality disorder (1-3), and the criteria delineating this diagnostic category have not yet been empirically evaluated. Our goat is to establish whether a discrete group of characteristics can reflect the clinical use of the nancissistic personality disorder diagnosis, and, if so, what relation these characteristics have to the set of DSMIII-R criteria. To do this we have developed a semistructured interview to assess the characteristics imputed to pathological narcissism in the literature and in our own clinical experience (4-6). In a prior report (7) we examined narcissistic traits in psychiatric patients. The present exploratory study investigated patients given the diagnosis of narcissistic personality disorder.
Received April 21, 1989; revisions received Oct. 26 and Dec. 6, 1989; accepted Jan. 1 1, 1990. From the Psychosocial Research Program, McLean Hospital. Address reprint requests to Dr. Gunderson, McLean Hospital, 1 15 Mill St., Belmont, MA 02178. Supported in part by grants from the Swedish Institute and Wallenberg Jubilee Foundation, Stockholm, and from the Psychosocial Research Program, McLean Hospital. The authors thank Ren#{233}Roy, M.D., and David Clinton, M.Appl.Sc., for their assistance. Copyright © 1990 American Psychiatric Association.
918
and John
Personality
Gunderson,
Disorder
M.D.
Most conceptually and descriptively difficult questions about the differential diagnosis of narcissistic personality involve borderline and antisocial personalities (8-14). In order to ascertain the best and most clinically useful criteria for narcissistic personality disorder, we chose a comparison group that included both patients with these “near-neighbor” conditions and patients with nonrelated psychiatric disturbances. We discuss the results from this study with respect to their implications for existing clinical and conceptual descriptions of pathological narcissism and for the DSM criteria.
METHOD The subjects of the study were 82 patients who gave written informed consent and met the selection cnitena: 1) they were 17-45 years of age, 2) they were capable of participating in a diagnostic interview, 3) they had no known organic impairment, and 4) they had official clinical diagnoses in any of the following categories. 1. Narcissistic personality disorder (N=24). To obtam narcissistic personality disorder patients who represented a reasonably prototypic sample, otherwise suitable patients were excluded if they had complicating axis I diagnoses, e.g., major psychosis on concurrent substance abuse. 2. Other “dramatic” cluster personality disorders, namely, borderline and antisocial (N=36). These diagnoses were confirmed by standardized interviews: the Diagnostic Interview for Borderline Patients (15) for the former and the Structured Clinical Interview for DSM-III-R Personality Disorders (16) for the tatter. Both interviews were conducted by trained, reliable interviewers. 3. Other psychiatric diagnoses (excluding the dnamatic cluster type of personality disorder) (N22). These diagnoses included (axis I) major depression (N 7), bipolar disorder (N=4), dysthymia (N= 1), schizophrenia (N=3), schizoaffective disorder (N 1), adjustment disorder (N=2), anorexia nenvosa (N= 1), and (axis II) mixed, atypical, and “anxious” cluster personality disorders (N=3). The official clinical diagnoses were established after 4-8 weeks of observation and were based on input from multiple sources. For inpatients the input was from administrative psychiatrists, psychotherapists, nuns-
Am
J
Psychiatry
1 47: 7, July
1990
ELSA
ing staff, and psychological and neurological testing. For outpatients the period of observation was usually much longer, and for them also, confirmatory second clinical diagnostic assessment by another professional was required for inclusion in our samples. This approach follows the “LEAD” (Longitudinal/Expert/Alt Data) standard (17). We had learned from previous studies (7, 18) that an adequate sample of patients with diagnoses of narcissistic personality disorder on antisocial personality disorder was not readily obtained from the accessible clinical services at our hospital. This was confirmed when we initiated this project by interviewing 45 suitable and consenting patients from the hospital’s inpatient and outpatient services. An additional 19 patients were then recruited by sending a memo to hospital staff members that specifically encouraged them to screen their practices for suitable patients and to gain permission for us to approach them. We also recruited 18 English-speaking patients from a correctional treatment institution who had had extensive psychiatric evaluations. Each subject was given the Diagnostic Interview for Narcissism (5, 6), which consists of 33 statements about characteristics, nine of which overlap with those in DSM-III-R. These statements are grouped into five sections: 1) grandiosity, 2) interpersonal relations, 3) neactiveness, 4) mood states, and 5) social/moral adaptation. The internal consistency for the entire interview is good (atpha=0.81), and the intenraten reliability is also acceptable for the statements (mean weighted kappa=0.68), the section scores (intractass R0.740.96, N= 18, p
