While Kipnis builds a seductive case, you get the sense she has underestimated narcissists. “Personality traits exist on a continuum,” says John Oldham, chief of staff at the Menninger Clinic and one of the leading voices for getting NPD into the DSM-5. “Someone with narcissistic personality disorder is at an extreme point on the continuum, a point that leads to incredible impairment at work, interpersonally, and socially.” In subclinical patients, self-confidence (the healthy isotope of narcissism) may shade into arrogance, but not Trump-level radioactive hazmat. Pure NPD, Oldham says, makes “people’s worlds fall apart.”
For psychiatrists, the question isn’t really “do narcissists exist” or “are narcissists any different from the rest of us.” It’s “are narcissists mentally ill?”
Behind this question lurks another one: What do we gain, and lose, from picking out a psychic phenomenon and declaring it “sick”? Are we needlessly stigmatizing ordinary behavior? Absolving jerks of responsibility for their trespasses? Conversely, given our more advanced understanding of mental illness as biological—a complicated interweaving of genetic, developmental, and environmental factors—are we being more humane? Making it easier for people who are suffering to find treatment?
“We all have a tendency—greater or less—to be selfish, and I don’t see it as helpful to discuss ‘narcissism’ and ‘narcissists’ in diagnostic terms,” writes the psychologist Peter Kinderman in The Conversation. His problem with the mental illness label: It is inaccurate, a contrived category for a pervasive human impulse. Our shared penchant for narcissism plays out to greater or lesser degrees, he claims, and we should concentrate on how “we all, me included, can be self-centred, lacking in compassion, lacking in empathy.”
Yet it seems strange to insist that, because small-N narcissism lives in everyone, narcissistic personality disorder can’t inhabit its own pathological real estate on the far end of the continuum. Anxiety disorders exist, though we all get anxious. And just as mental illness itself has undergone a transformation from perceived moral failing to medical ailment, perhaps we can begin to see certain persistent dispositions as disabilities rather than spiritual flaws.
Psychologists are largely in the dark about what causes NPD. A study of 175 volunteer twin pairs (90 identical, 85 fraternal) suggested that narcissism is a highly heritable trait, but few labs have looked at what triggers the full-blown personality disorder. Adoption studies of antisocial personality disorder support the claim that environment plays a role in this roster of illnesses. Some experts posit that NPD, which tends to manifest by early adulthood, sprouts from “excessive pampering” or a self-serving parental “need for their children to be talented and special.” The most common causal model, however, imagines a skein of interrelated biological, social, and psychological factors, in which a predilection lurking in your DNA may flower heinously with the right combination of childhood experiences, learned behaviors, and nurtured quirks.
One reason personality disorders are so challenging may be that qualities like narcissism seem too close, too innate, to fit under the mental illness umbrella. Your depression or anxiety does not have to define you, but your personality might. Traditionally, the biological view of mental disorders is seen as kinder than its alternatives (“There’s something wrong with your brain! It’s not your fault.”), but it also implies a kind of life sentence, an irrevocability. Subjecting your very character to judgments of sickness or health has the potential to sear pathology into the core of your identity.
Doctors are pushing back on that sense of hopelessness and stigma. “One definition of illness is ‘something we treat,’ ” says Andrew Skodol, a psychiatry professor at the University of Arizona and a specialist in NPD. Yes, he continues, narcissism is treatable. Especially in conjunction with medication, psychotherapy can relax the grip of the disorder and nudge patients closer to the safe middle of the spectrum.
In fact, narcissism’s responsiveness to treatment may be the strongest argument for including it in the DSM. When you are suffering from something you can’t quite control and that professionals have insight into managing, the best thing to do is seek help. Fewer people will attempt to grapple with their narcissism if they do not consider it a disorder. Skodol’s utilitarian argument for pathologizing self-centeredness is based on these two facts: Personality traits appear to be partly inborn, though malleable—that is, they are conditions rather than choices—and therapists can guide narcissists through the hard process of containing their egos and building their lives.
For Skodol and Oldham, recognizing NPD as a “condition” does not mean releasing narcissists from accountability for their actions. “Even if you have a mental illness, you have to do your best,” says Oldham.
As it stands, many doctors are still dissatisfied with the DSM-5’s portrait of narcissism. A recent paper points out that the description, with its brief and broad list of symptoms, overlooks the nuances of the syndrome’s nature (from normal to pathological), structure (as a category but also a dimension), presentation (are you grandiose or painfully vulnerable?), and expression (is your narcissism overt or kept hidden?). Yet including the condition in America’s field guide to psychological disorders is a good thing. Whether they are maligned for being selfish sons-of-bitches or considered mentally ill, narcissists will probably face a measure of stigma. They might as well get some help too.