Dimensional Approach to Diagnosing NPD Leads to More Successful Treatment


A dimensional approach to understanding and diagnosing narcissistic personality disorder (NPD) as outlined in Section III of DSM-5—focusing the patient’s functioning with regard to identity, self-direction, empathy, and intimacy—marks a significant improvement over a strictly trait-based diagnostic system.

That’s what Elsa Ronningstam, Ph.D. (pictured above), of McLean Hospital told psychiatrists today in the lecture “Dimensional Conceptualization and Diagnosis of Narcissistic Personality Disorder” at APA’s 2016 Annual Meeting in Atlanta. She was joined by Igor Weinberg, Ph.D., also of McLean, who discussed comorbidity of other mental disorders frequently seen in patients with NPD and suicidality among patients with NPD.

Ronningstam said the dimensional approach to NPD helps to identify the patient’s fluctuating self-esteem and co-occurrence of both self-enhancing grandiosity and self-depleting vulnerability; it can also aid the clinician in differentiating temporary fluctuating or externally provoked features and patterns from more enduring traits of pathological narcissism. Additionally, the dimensional approach helps clinicians recognize the patient’s internal suffering related to insecurity, self-criticism, anxiety, shame, and fear—which are likely to be masked by the patient’s grandiosity and domineering surface presentation.

She described a flexible, exploratory, and collaborative diagnostic process that integrates the patient’s subjective experiences and interpersonal functioning in a way that is informative and meaningful for both clinician and patient.

“Encouraging self-assessment and the patient’s own narratives of their performance, anticipations, and aspirations and shifts in states, self-esteem, and emotions can begin to bridge the different perspectives of the patient and the clinician, and help reach a diagnostic agreement and understanding of the patient’s functioning,” she said. “With regard to the diagnosis of NPD, these changes represent significant improvement compared with the entirely trait-based diagnosis.”

(Image: David Hathcox)