And finally, the DSM-TR defines narcissistic personality disorder as a pattern of grandiosity, need for admiration, and lack of empathy.

What does the text revision have to say about cluster B in general?

It says cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders.

I remind you, by the way, that cluster B is also known as erratic and dramatic or dramatic personality disorder.

The DSM continues, individuals with these cluster B disorders often appear dramatic, emotional, or erratic.

A review of epidemiological studies from several countries found a median prevalence of 3.6% for disorders in cluster A, 4.5% for cluster B, 2.8% for cluster C, and 10.5% for any personality disorder.

Prevalence appears to vary across countries and by ethnicity, raising questions about true cross-cultural variation and about the impact of diverse definitions and diagnostic instruments on prevalence assessments.

I would even add and say that such variants among cultures may raise the possibility that these are not real clinical entities at all, but culture-balanced syndromes.

But that’s a debate for another time.

And the DSM-5 introduces dimensional models for personality disorders.

It explains these models in the following way.

The diagnostic approach used in this manual represents the categorical perspective that personality disorders are qualitatively distinct clinical syndromes.

An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another.

By the way, I’ve been advocating this since 1995. And so they created in the text revision, actually in the DSM-5, they created a whole section dedicated to this alternative dimensional model.

Section three, and there’s a full description of the dimensional model for personality disorders in that section.

The DSM continues to say, the DSM-5 personality disorder clusters, odd, eccentric, dramatic, emotional, and anxious, fearful, may also be viewed as dimensions representing spectra of personality dysfunction on a continuum with other mental disorders.

Yes, exactly, DSM.

The alternative dimensional models have much in common and together appear to cover the important areas of personality dysfunction.

Here’s to many.

Their integration, clinical utility, and relationship with the personality disorder diagnostic categories and various aspects of personality dysfunction continue to be under active investigation.

They need to establish the validity of these alternative models.

This includes research on whether the dimensional model can clarify the cross-cultural prevalence variations seen with a categorical model.

Okay, let’s get to business.

And our business, of course, is cluster B personality disorders.

In this video, I’m going to cover narcissistic personality disorder.

The survivors of this video can proceed in the future to other videos in which I will cover borderline personality disorder and antisocial personality disorder, as well as psychopathy.

Okay, let’s start with narcissistic personality disorder in a few breaking news.

Prevalence. I’m reading from the text. The estimated prevalence of narcissistic personality disorder based on a probability sub-sample from part two of the national comorbidity survey replication and the national epidemiologic survey on alcohol and related conditions.

So this prevalence was actually 6.2%.

Yes, all of you were right. Narcissism is far more widespread than was given credit for in previous editions of the DSM.

A review of five epidemiological studies for in the United States found a median prevalence of 1.6%.

So there is still a big debate as to how prevalent narcissism is. But taking into account, for example, the fact that narcissists are reluctant to attend therapy or to be diagnosed, I think the 6% is closer to the mark, between three and five definitely.

What about sex and gender related features?

The DSM has this to say.

Among adults aged 18 and older diagnosed with narcissistic personality disorder, 50 to 75% are men.

So for the first time or for the second time, actually, the DSM accepts that about 50% of all people diagnosed with NPD are actually women.

This is a major explosion in the diagnosis of narcissism, pathological narcissism among women.

Gender differences, the text continues, gender differences in adults with this disorder include stronger reactivity in response to stress and compromised empathic processing in men, as opposed to self-focus and withdrawal in women.

As I’ve been saying, women and men manifest, express narcissistic personality disorder differently. Culturally based gender patterns, says the DSM, and expectations may also contribute to gender differences in narcissistic personality disorder, traits and patterns.

So gender bias and even misogyny are reflected in the work on narcissistic personality disorder over the decades, starting 107 years ago.

What happened to the diagnostic criteria?

In short, nothing since the DSM edition three text revision, we’re talking 40 plus years, something is wrong with that.

We know a lot more about narcissistic personality disorder than we had known in 1980. And yet the text has the text of the diagnostic criteria has changed very little, if at all.

This doesn’t sound right, but at any rate, I’m going to read the text to you.

Diagnostic criteria, F60.81.

A pervasive pattern of grandiosity in fantasy or behavior, need for admiration and lack of empathy, beginning by early adulthood, presented and present in a variety of contexts, as indicated by five or more of the following diagnostic criteria.

Number one is a grandiose sense of self importance.

Example exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements.

Number two is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

Number three, ideal love, by the way, is what I call in what Sanger called shared fantasy.

Number three 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.

Number four requires excessive admiration.

Number five, bring it on, bring it on.

Number five has a sense of entitlement.

In other words, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.

Number six is interpersonally exploitative, takes advantage of others to achieve his or her own ends.

Number seven lacks empathy, is unwilling to recognize or identify with the feelings and needs of others.

Number eight is often envious of others or believes that others are envious of him or her.

Number nine shows arrogant, haughty behaviors or attitudes.

By the way, those of you who want to view, want to actually read these criteria, it’s on page 760.

Much more important than the diagnostic criteria to my mind is the text.

Now the text which describes the narcissist, his functioning, his interpersonal relationshipsand his internal landscape, the text had been revised, had been revised in each and every edition of the DSM, and the text revision of DSM-5 is no exception.

There are few revisions to the text. Rather than point out the differences, I’m going to simply read the entire text to you because it’s an excellent introduction to the narcissist, to pathological narcissism, and a counterweight to many nonsensical self-styled experts with and without academic degrees.

Listen well, this is the Bible of the psychiatric profession. Ignore most of the trash online.

Here’s what the DSM text revision has to say about narcissistic personality disorder, starting with its diagnostic features.

The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood, by early adulthood, not earlier, and present in a variety of contexts.

Individuals with this disorder have a grandiose sense of self-importance, which may be manifest as an exaggerated or unrealistic sense of superiority, value, or capability. They tend to overestimate their abilities and amplify their accomplishments, often appearing boastful and pretentious.

Yes, yes, I hear you. They may blithely assume that others attribute the same value to their efforts and may be surprised when the praise they expect and feel they deserve is not forthcoming.

Often implicit in the inflated judgments of their own accomplishments is an underestimation or devaluation of the contributions of other people.

Individuals with narcissistic personality disorder are often preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. They may ruminate about long overdue admiration and privilege and compare themselves favorably with famous or privileged people.

Now, before I proceed, the alternative model, which I will read to you later, modifies this and it modifies this to incorporate the latest research which demonstrates conclusively that all this is a facade. It’s a compensatory effort. The narcissist deep inside feels inferior, feels empty, feels inadequate, and he tries to compensate for this by pretending to be exactly the opposite.

But this does not appear in edition four and the text revision of edition four. It makes an appearance for the first time subtly in the DSM-5 and openly and explicitly in this text revision.

So the alternative model is very important, much more important than the classical 40 years old diagnostic criterion. And still, I’m going to present to you the entire text so that you can form your own opinions and make up your own minds.

Individuals, the text continues, individuals with narcissistic personality disorder believe that they are special or unique and expect others to recognize them as such. They can be surprised or even devastated when the recognition of a claim that they expect and feel that they deserve from others is not forthcoming.

They may feel that they can only be understood by and should only associate with people of high status and may attribute unique, perfect, or gifted qualities to those with whom they associate.

This is the process of co-idealization. Individuals with this disorder believe that their needs are special and beyond the canon of ordinary people. Their own self-esteem is enhanced, mirrored by the idealized value that they assign to those with whom they associate co-idealization.

They are likely to insist on having only the top person, doctor, lawyer, hairdresser, instructor, or they would insist on being affiliated with the best institutions, but they may devalue the credentials of those who disappoint them.

Individuals with this disorder generally require excessive admiration. Their self-esteem is almost invariably very fragile, and their struggle with severe internal self-doubt, self-criticism, and emptiness results in their need to actively seek others’ admiration.

Here we come to the compensatory aspect of narcissism. This is why we are beginning to think that narcissists who are egotistonic, narcissists who don’t feel inferior, narcissists who don’t feel inadequate are actually not narcissists at all, but psychopaths.

What we used to call the overt grandiose narcissist is probably a subspecies or subvariant of a psychopath, and the only real narcissist is the overt or grandiose narcissist who is compensatory, compensates for a lack of inner conviction, for a very harsh inner critic, for unrelenting self-criticism.

This would be a true narcissist or a covert narcissist. That’s another variant of a true narcissist.

The text continues, narcissists may be preoccupied with how well they’re doing and how favorably they are regarded by others. They may expect their arrival to be greeted with great fanfare, and they are astonished if others do not covet their positions. They may constantly fish for compliments, often with great charm.

This is something I call false modesty.

The narcissist continues the text. The narcissist has a sense of entitlement which is rooted in their distorted sense of self-worth, and it is evident in these individuals’ unreasonable expectation of especially favorable treatment. They expect to be catered to and are puzzled or furious when this does not happen.

For example, they may assume that they do not have to wait in line and that their priorities are so important that others should defer to them and then get irritated when others fail to assist in their very important work.

They expect to be given whatever they want or feel they need, no matter what it might mean to others. For example, these individuals may expect great dedication from others, may overwork others without regard for the impact on other people’s lives.

This sense of entitlement, combined with a lack of understanding and sensitivity to the wants and needs of others, may result in the conscious, unwitting exploitation of other people.

Narcissists tend to form friendships or romantic relationships only if the other person seems likely to advance their purposes or otherwise enhance their self-esteem, source of narcissistic supply.

They often usurp special privileges and extra resources that they believe they deserve.

Some individuals with Narcissistic Personality Disorder intentionally and purposefully take advantage of others emotionally, socially, intellectually or financially for their own purposes and gains.

This would be the psychopathic end of the spectrum, by the way. This would be the psychopathic or malignant narcissist.

Continuing the text, individuals with Narcissistic Personality Disorder generally have a lack of empathy and are unwilling to recognize or identify with the desires, subjective experiences and feelings of other people. They tend to have some degree of cognitive empathy. That’s what I call cold empathy. Cognitive empathy is one component of cold empathy. Cold empathy is reflexive empathy plus cognitive empathy.

So, coming back to the text, narcissists tend to have some degree of cognitive empathy. That’s a major departure from previous DSM editions, by the way.

Some degree of cognitive empathy, understanding another person’s perspective on an intellectual level.

But narcissists lack emotional empathy, directly feeling the emotions that another person is feeling.

These individuals may be oblivious to the hurt their remarks may inflict. For example, exuberantly telling a former lover that I’m now in the relationship of a lifetime or boasting of health in front of someone who is terminally ill.

When recognized, the needs, desires or feelings of other people are likely to be viewed disparagingly, signs of weakness or vulnerability.

Those who relate to individuals with Narcissistic Personality Disorder typically find an emotional coldness and lack of reciprocal interest.

These individuals are often envious of others or believe that others are envious of them. They may begrudge others their successes or possessions, feeling that they better deserve those achievements, admiration or privileges. They may harshly devalue the contributions of other people, particularly when those individuals have received acknowledgement or praise for their accomplishments.

Arrogant, haughty behaviors, characterized narcissists, they often display snobbish, disdainful or patronizing attitudes. These are the diagnostic features.

What about the clinical picture, what we call the associated features?

The text says, vulnerability in self-esteem makes individuals with Narcissistic Personality Disorder very sensitive to criticism or defeat. Although they may not show it outwardly, such experiences may leave them feeling ashamed, humiliated, degraded, hollow and empty. They may react with disdain, rage or counter-attack, however, such experiences can also lead to social withdrawal or an appearance of humility that may mask and protect the grandiosity.

I’ve described this in my writings decades ago, how narcissists become schizoid, how they withdraw when they are narcissistically injured, let alone mortified. I also describe false modesty or pseudo humility.

Interpersonal relations continue, they are typically impaired because of problems related to self-preoccupation, entitlement, need for admiration and relative disregard for the sensitivities of others.

Individuals with Narcissistic Personality Disorder can be competent and high-functioning with professional and social success, while others can have various levels of functional impairment.

So we have high-functioning narcissism, low-functioning narcissism. Professional capability combined with self-control, stoicism and interpersonal distancing with minimal self-disclosure can support sustained life engagement and even enable marriage and social affiliations.

Sometimes ambition and temporary confidence lead to high achievements, but performance can be disrupted because of fluctuating self-confidence and intolerance of criticism or defeat.

Do you hear this Donald Trump? Some individuals with Narcissistic Personality Disorder have very low vocational functioning, reflecting an unwillingness to take a risk in competitive or other situations in which failure or defeat can be possible.

Narcissists also, may I add, lazy and some of them are perfectionists which causes them to procrastinate or avoid tasks altogether. That’s my my vision.

Back to the text. Low self-esteem with inferiority, vulnerability and sustained feelings of shame, envy and humiliation accompanied by self-criticism and insecurity can make individuals with Narcissistic Personality Disorder susceptible to social withdrawal, emptiness and depressed mood.

Finally, there’s a revolutionary part and reflects everything I’ve been saying in this channel for almost 15 years.

High perfectionist standards are often associated with significant fear of exposure to imperfection, failure and overwhelming emotions.

What does a DSM 5 text revision have to say about the development of Narcissistic Personality Disorder in the course of the disorder, the trajectory?

Here too, the text has been revised to reflect current knowledge. Narcissistic traits, says the text, may be particularly common in adolescents, but do not necessarily indicate that the individual will develop Narcissistic Personality Disorder in adulthood.

Yes, I’ve been saying it for many, many years. Adolescents are narcissists. People, infants at age 2 are narcissists.

Healthy narcissism is crucial to separation, individuation and identity formation.

The DSM continues, predominant Narcissistic traits or manifestations of the full disorder may first come to clinical attention or be exacerbated in the context of unexpected or extremely challenging life experiences or crises, what I call hitting rock bottom.

What kind of crises, bankruptcies, demotions, loss of work or divorces, suggests the DSM.

In addition, says the DSM, individuals with Narcissistic Personality Disorder may have specific difficulties adjusting to the onset of physical and occupational limitations that are inherent in the aging process.

Tell me about it.

However, life experiences such as new, durable relationships, real, successful achievements and tolerable disappointments and setbacks can all be corrective and contribute to changes and improvements in individuals with this disorder.