How is narcissism diagnosed?

By Elinor Greenberg

There are multiple ways to diagnose Narcissistic Personality Disorder. Which ones specific therapists choose to use depends mainly on their training and the purpose of the disgnosis.

DSM5: This is a diagnostic manual that supplies symptom check lists for different mental disorders. Every disorder gets a number. This type of manual is mainly used to help a client get insurance reimbursement or to satisfy the requirements of an agency or hospital that employs the psychotherapist. It is not subtle and does not address or recognize anyone as a Narcissist who is not acting out in easily observed ways that can be counted.

History and Presenting Problems: During clients’ first sessions, it is common to take a history and ask about why they are seeking therapy now.

Narcissistic Histories: Certain factors pop up repeatedly in the histories of people who turn out to suffer from Narcissistic disorders:

Parents espoused a Narcissistic value system that divided the world into two groups—successes or failures.

There was a family emphasis on achievement or failure.

The parents used shaming, humiliation, and devaluation as primary methods for instructing and punishing the child.

The parents were perfectionists who expected and rewarded the children only when they got all “A’s” on the report card, came in first in the race, or won the lead in the school play.

The parents were extremely hierarchical in thinking and very status consciousness.

One of the parents (or both) were Narcissists and expected to always be the center of admiring attention, or else they would explode angrily.

The rest of the family tipped-toed around the explosive parent.

Typical Narcissistic Presenting Problems:

My wife says she will leave me if I do not come to therapy.

My boss says that although I bring in a lot of money to the firm, I need to go to therapy because my colleagues complain that I insult and belittle them.

I am in a shame-based, self-hating depression because I feel like a failure.

No one appreciates how special I am. I have been robbed of what I deserve by malicious, ignorant, jealous idiots.

Diagnosis by Transference: The clients projects one of the following onto the therapist:

Idealizing Transference: You are perfect and special. I admire you.

Devaluing Transference: You are worthless garbage. I despise you.

Twinship Transference: We are special and alike. Everyone should admire us.

Exhibitionist Transference: I am special and your role is to be my admiring audience.

Diagnosis by Countertransference: This focuses on how being with the client makes the therapist feel. Here are some common reactions.

I am special. (A reaction to the client’s excessive idealization).

I am beginning to be filled with an uncharacteristic self-doubt. (A reaction to the client’s persistent devaluation).

I am bored. (This client is talking endlessly about the details of what he had for lunch and who was there and every time the therapist tries to interrupt, the client ignores the therapist and continues the boring monologue).

I am angry. (A reaction to the client’s story of devaluing helpless people who could not retaliate).

I am afraid to say anything for fear of getting attacked by the client. (This client scares me).

I am afraid to say anything because the client is easily offended and tends to leave situations and never come back. (I want to keep the client and do therapy, but I do not know how to do both).

The Narcissistic Interpersonal Gestalt: This involves noticing which interpersonal details the client repeatedly makes foreground and which the client repeatedly fails to notice.

Narcissists typically notice:

Status Markers: Such as whether my office is in an upscale neighborhood, how many diplomas I have on my wall, the estimated cost of my furniture or clothing, etc.

Interruptions to the Session: My Narcissistic clients deeply resent it if someone rings my doorbell during their session. If I need to get up to see who it is, some clients will spend the rest of the session berating me.

If I agree with them: I try not to judge my client’s actions. That is not my job. Some very Narcissistic clients interpret my neutrality as disapproval and will stop the session and start an argument with me because they need total agreement.

Narcissists often do not notice when they are:

Story Telling: Repeating the same story word for word without remembering that they have already told it to me (and others) multiple times.

Taking more than their share: For example: Their session is over, they know another client has arrived and is waiting to enter, and yet they say: I know there is no more time, but I have just one more thing I would like to say before I leave—and they make everyone wait while they keep on talking.

Asking for special treatment that inconveniences me. For example: They want to be sent a bill at the end of the month, instead of paying each session like everyone else. They want to cancel with no notice and not be charged.

Having a negative impact on other people. They are focused on themselves and what they want to say or do and are oblivious that the other person is feeling bored, frustrated, hurt, or overwhelmed in response to their behavior.

Punchline: There are many ways to diagnose Narcissistic Personality Disorder. I have only listed a few of my favorites that I use regularly. There are also different schools of thought about where the line between normal Narcissism and pathological Narcissism should be drawn. I generally advise therapists to use the ones that work best for them.