Narcissistic Personality Disorder in DSM-V—In Support of Retaining a Significant Diagnosis

What This Research Found

Elsa Ronningstam’s influential paper was written to save a diagnosis. During the DSM-5 revision process, the committee proposed eliminating narcissistic personality disorder as a standalone diagnosis, replacing it with dimensional trait ratings. Ronningstam, drawing on decades of clinical work with narcissistic patients at McLean Hospital and Harvard Medical School, marshalled the evidence for NPD’s retention. Her arguments succeeded, and the paper remains a definitive statement of why narcissistic personality disorder matters as a clinical entity.

The coherence of narcissistic personality disorder. Ronningstam demonstrates that NPD is not merely a collection of traits but a coherent personality organisation. The features interlock: grandiosity defends against intolerable shame; the need for admiration stems from inability to generate stable self-worth internally; exploitation of others follows from experiencing people as extensions of the self rather than separate beings with their own needs; empathy deficits both enable exploitation and prevent the genuine connection that might heal the underlying wound. Understanding NPD as a syndrome rather than a trait cluster has direct clinical implications—treatment must address the underlying structure, not simply target surface behaviours.

The grandiose-vulnerable spectrum. Ronningstam emphasises that narcissistic personality disorder manifests across a spectrum from overtly grandiose to predominantly vulnerable presentations. The grandiose narcissist matches popular stereotypes: arrogant, attention-seeking, openly superior. The vulnerable narcissist presents differently—apparently sensitive, easily wounded, preoccupied with slights and disappointments, presenting as a victim of others’ failures to recognise their worth. Both share the same underlying dynamics: fragile self-esteem requiring constant external regulation, inability to genuinely recognise others as separate beings, exploitation of relationships for self-esteem maintenance. Many narcissists oscillate between presentations depending on whether narcissistic supply is abundant (grandiose) or depleted (vulnerable). Failure to recognise vulnerable presentations leads to misdiagnosis and misguided treatment.

The self-esteem dysregulation at NPD’s core. Rather than stable high self-regard, narcissists experience chronic self-esteem instability—oscillating between grandiosity and devastating feelings of worthlessness. This dysregulation drives the constant pursuit of external validation: without stable internal self-worth, the narcissist requires continuous external confirmation that they are special. Any failure of validation threatens narcissistic collapse. Ronningstam’s framework explains why narcissists cannot tolerate criticism, why their need for admiration is insatiable, and why they react to minor slights with disproportionate narcissistic rage or withdrawal.

The distinctive therapeutic challenges. Ronningstam addresses directly why narcissistic patients are among the most difficult in psychiatric practice. They rarely seek treatment voluntarily, and when they do, it is typically to manage external circumstances rather than to change themselves. They enter therapy expecting validation rather than examination, and experience therapeutic confrontation as narcissistic injury. They idealise therapists initially, then devalue them when the therapist fails to provide unlimited admiration or dares to challenge their self-perception. Their defenses actively prevent the emotional engagement that therapy requires. Most leave treatment prematurely. Those who stay often show minimal change. This treatment resistance is not incidental but constitutive of the disorder—the same structures that create narcissistic pathology prevent its modification.

Why This Matters for Survivors

If you have been harmed by a narcissist, Ronningstam’s work offers both validation and explanation.

Your experience of exploitation was real and documented. Clinical literature confirms that narcissistic individuals systematically use others for self-esteem regulation while remaining fundamentally unable to reciprocate genuine care. The confusion you felt—sensing something was deeply wrong while the narcissist seemed to understand your feelings—reflects the distinction between cognitive and affective empathy. They could read your emotions; they simply were not moved by them. Your feelings existed in their world only as data about how to manage you.

Vulnerable narcissism explains the victim who exploited you. Many survivors encountered narcissists who presented not as arrogant but as suffering, not as superior but as wounded. Ronningstam’s work validates that this presentation exists and is particularly dangerous. The vulnerable narcissist elicits compassion and care, then exploits that empathy as a form of supply. If you gave endlessly to someone who presented as fragile yet somehow left you depleted and doubting yourself, you may have encountered vulnerable narcissism. Your instinct that the suffering was somehow weaponised was clinically accurate.

The treatment resistance you witnessed was characteristic of the disorder. If you hoped the narcissist would change—through therapy, through your love, through consequences—Ronningstam’s research explains why change so rarely occurs. The narcissistic personality structure exists to prevent the very self-examination that change would require. The person you knew was not choosing to remain unchanged; their entire psychological organisation was designed to maintain the false self at all costs. This knowledge can release you from hope that keeps you attached to someone incapable of reciprocity.

Your compassion was exploited by design. Ronningstam specifically identifies how vulnerable narcissists target others’ empathy as a source of supply. If you are a compassionate person—someone inclined to help those who seem to be suffering—you were particularly vulnerable to exploitation by this presentation. Your compassion was not weakness; it was a strength the narcissist identified and instrumentalised. Understanding this dynamic can help you protect yourself in future relationships without abandoning the capacity for care that makes you who you are.

Clinical Implications

For psychiatrists, psychologists, and trauma-informed healthcare providers, Ronningstam’s work offers essential guidance for assessment, treatment, and understanding the challenges narcissistic patients present.

Recognise the full spectrum of narcissistic presentation. Clinicians trained to identify narcissism through overt grandiosity will miss vulnerable presentations that appear as depression, anxiety, or chronic victimhood. Probe beneath surface symptoms: Does the apparently depressed patient harbour grandiose fantasies they feel the world has failed to recognise? Does the anxious patient’s distress centre on not receiving special treatment? Does the victim presentation serve to extract caretaking and validation? The underlying dynamics of fragile self-esteem, empathy deficits, and exploitative relating may be present even when grandiosity is hidden.

Prepare for the therapeutic relationship to become the treatment arena. Narcissistic patients will enact their patterns with the therapist. Expect initial idealisation (“You’re the first person who truly understands me”) to give way to devaluation when you fail to provide unlimited validation or challenge their self-perception. This is not treatment failure but diagnostic data and therapeutic opportunity. The therapist’s capacity to maintain empathic engagement while refusing to collude with grandiosity models a relationship dynamic the patient has never experienced. This is difficult work requiring robust self-care and clinical supervision.

Manage expectations about treatment outcomes. Ronningstam’s research supports realistic rather than nihilistic expectations. Full personality change is rare, but harm reduction is possible. Some narcissistic patients, particularly those with prominent vulnerable features who experience genuine suffering, may engage meaningfully in treatment during extended periods. Crisis presentations (narcissistic collapse following major loss of supply) may create temporary treatment motivation, though this typically fades as the crisis resolves. Communicate realistic expectations to patients and, when relevant, to their families.

Differentiate from other Cluster B presentations. The overlap between narcissistic, borderline, and antisocial presentations creates diagnostic confusion. Ronningstam’s emphasis on self-esteem dysregulation and the grandiose-vulnerable oscillation helps distinguish NPD from borderline identity diffusion (unstable self-concept versus defensive grandiosity) and from antisocial personality (instrumental versus self-esteem-driven exploitation). Accurate diagnosis matters because treatment approaches differ substantially across these conditions.

Support survivors therapeutically. Patients who have been harmed by narcissists—partners, children, subordinates—present with characteristic patterns: shattered self-worth, difficulty trusting their own perceptions after sustained gaslighting, trauma bonds that persist despite conscious understanding, and often hypervigilance to criticism or disapproval. Understanding Ronningstam’s framework helps clinicians explain what patients experienced and why normal responses (empathy, accommodation, hope) were exploited. Validation of the patient’s reality—that the abuse was real even when the narcissist presented as the victim—is often profoundly therapeutic.

Broader Implications

Ronningstam’s work on narcissistic personality disorder extends beyond individual diagnosis and treatment to illuminate patterns affecting families, institutions, and social systems.

The Challenge of Vulnerable Narcissism in Helping Professions

Mental health professionals, social workers, healthcare providers, and others drawn to helping roles are particularly vulnerable to exploitation by vulnerable narcissists. These individuals present as suffering, misunderstood, uniquely sensitive—precisely the presentation that activates helpers’ professional and personal identities. The helper extends compassion; the vulnerable narcissist experiences this as supply and intensifies the demands. Boundaries are experienced as abandonment or cruelty. The helper, trained to care for the suffering, may struggle to recognise that the suffering is being weaponised. Supervision and consultation must include attention to this dynamic, protecting helpers from exploitation while maintaining their capacity for genuine care.

Diagnostic Validity and Its Policy Implications

The DSM-5 debate that prompted Ronningstam’s paper reveals how diagnostic categories shape clinical practice, research funding, and public understanding. Had NPD been eliminated, research programmes would have been disrupted, clinical training would have shifted, and public awareness of narcissistic abuse would have lost its clinical anchor. The successful retention of NPD demonstrates that clinical advocacy matters—and that the categories we use to name psychological phenomena have consequences beyond academic classification. As dimensional models gain prominence in personality disorder research, Ronningstam’s arguments for categorical coherence remain relevant for how we understand and communicate about personality pathology.

Family Court and Custody Implications

Narcissistic parents in custody disputes often present as victims—wounded by the other parent’s cruelty, desperately concerned for their children’s welfare. Ronningstam’s framework for understanding vulnerable narcissism is directly applicable to forensic contexts. Evaluators who recognise only grandiose narcissism may be manipulated by vulnerable presentations that appear sympathetic and reasonable. The capacity for impression management that Ronningstam identifies means narcissistic parents may present well in structured evaluation settings while behaving destructively in intimate family contexts. Courts and evaluators would benefit from training in the full spectrum of narcissistic presentation.

Workplace Recognition and Institutional Vulnerability

Organisations are often vulnerable to narcissistic individuals who present as visionary leaders or uniquely valuable contributors. Ronningstam’s work helps explain how narcissists manipulate institutional contexts: they identify what the organisation values and present themselves as uniquely able to deliver it, they cultivate powerful supporters while devaluing those who see through them, and they experience accountability as persecution. Understanding the grandiose-vulnerable oscillation helps organisations recognise when a seemingly vulnerable employee’s claims of mistreatment may reflect narcissistic dynamics rather than genuine victimisation.

The Limits of Compassion-Based Intervention

Ronningstam’s analysis of how narcissists exploit others’ empathy has implications for how we think about social change. Approaches that rely on appealing to perpetrators’ compassion—restorative justice programmes, empathy-based interventions, therapeutic confrontations designed to help abusers “understand the impact of their behaviour”—may be fundamentally limited when applied to narcissistic individuals. Their empathy deficits are structural, not merely attitudinal. Interventions must work around rather than through the capacity for genuine care that narcissists lack.

Public Mental Health Literacy

As awareness of narcissistic abuse has grown in public discourse, understanding Ronningstam’s clinical framework can improve public mental health literacy. The term “narcissist” is often applied loosely to anyone perceived as selfish or arrogant. Ronningstam’s work helps distinguish between normal self-centredness and genuine personality pathology, between healthy confidence and grandiosity that masks fragility, between temporary victimhood and vulnerable narcissism that systematically exploits others’ compassion. More accurate public understanding could improve recognition of genuine pathology while reducing misuse of clinical terminology.

Limitations and Considerations

Ronningstam’s paper, while authoritative, should be understood within appropriate limits.

The advocacy context. The paper was written specifically to argue for NPD’s retention in DSM-5, which may have shaped how evidence was presented. While the arguments are well-supported, this is advocacy as well as scholarship. Dimensional models of personality pathology have genuine strengths that the paper necessarily downplays in making its case for categorical diagnosis.

Clinical sample limitations. Ronningstam’s clinical experience, while extensive, draws primarily from patients who sought or were referred for treatment—a subset that may differ systematically from the larger population of narcissistic individuals who never enter clinical settings. The most successful narcissists, those whose pathology is rewarded in professional or social contexts, may never appear in clinical samples that inform this research.

Treatment pessimism. While Ronningstam accurately describes the challenges of treating narcissistic patients, some critics argue that therapeutic pessimism may become self-fulfilling. If clinicians expect narcissistic patients to be untreatable, they may invest less effort or terminate treatment prematurely. The appropriate balance between realistic expectations and therapeutic hope remains debated.

Cultural context. The framework was developed primarily in Western clinical contexts. How narcissism manifests across cultures, whether diagnostic criteria capture culturally-variant expressions of similar underlying dynamics, and whether treatment approaches translate across cultural contexts remain incompletely understood.

How This Research Is Used in the Book

Ronningstam’s work appears in Narcissus and the Child to illuminate the distinctive challenges narcissistic individuals pose—both for those who try to help them and for those harmed by them. In Chapter 1: The Face in the Pool, her research helps explain why vulnerable narcissists are particularly difficult to recognise and resist:

“Vulnerable narcissists particularly challenge our compassion. These individuals present as victims, eliciting sympathy and care, but their victimhood is there to feed off others’ empathy—turning it into a form of validation and manipulation.”

The chapter also draws on Ronningstam’s clinical experience to describe the particular burden mental health professionals face when working with narcissistic patients:

“Mental health professionals face particular challenges in maintaining therapeutic compassion for narcissistic patients. These patients actively devalue therapists and terminate treatment when challenged. Yet some narcissists, particularly those facing narcissistic collapse, can engage in meaningful therapy.”

In Chapter 3: The Borderline Sibling, Ronningstam’s work helps contrast borderline treatability with narcissistic treatment resistance, explaining why one condition often improves with appropriate intervention while the other stubbornly persists:

“Narcissistic personality disorder stubbornly refuses to budge from the pool. The very features that define narcissism prevent engagement with treatment. Most narcissists never seek help, and those who do often leave prematurely or show minimal improvement.”

The chapter uses Ronningstam’s framework to explain why the narcissist cannot be loved into health by a devoted partner or reasoned into change by a skillful therapist—the personality structure exists precisely to prevent the vulnerability that change would require.

Further Reading

• Ronningstam, E. (2005). Identifying and Understanding the Narcissistic Personality. Oxford University Press.
• Ronningstam, E. (2012). Alliance building and narcissistic personality disorder. Journal of Clinical Psychology, 68(8), 943-953.
• Ronningstam, E. (2017). Intersect between self-esteem and emotion regulation in narcissistic personality disorder: Implications for alliance building and treatment. Borderline Personality Disorder and Emotion Dysregulation, 4, 3.
• Ronningstam, E. & Weinberg, I. (2023). Narcissistic personality disorder: Patterns, processes, and indicators of change in long-term psychotherapy. Journal of Personality Disorders, 37(3), 337-357.
• Pincus, A.L. & Lukowitsky, M.R. (2010). Pathological narcissism and narcissistic personality disorder. Annual Review of Clinical Psychology, 6, 421-446.
• Kernberg, O.F. (1975). Borderline Conditions and Pathological Narcissism. Jason Aronson.