Controversy Associated with Personality and Paraphilic Disorders


Controversy Associated with Personality and Paraphilic Disorders


Narcissistic personality disorder (NPD) is a cluster B personality disorder with dramatic, emotional, and erratic behavior. It manifests with a persistent pattern of grandiosity, an increased sense of self-importance, and an obsession with fantasies of great success. The purpose of this paper is to discuss the controversy surrounding NPD, maintaining a therapeutic relationship with NPD patients, and ethical and legal considerations.

Controversy That Surrounds NPD

Controversies surrounding NPD have surfaced regarding the definition of grandiose and vulnerable features present in the disorder. Questions have come up on various issues, including whether a universal description of NPD exists, the differences between normal and pathological narcissism, the central and peripheral characteristics of narcissism, the possible etiology, and the role of self-esteem in NPD (Crowe et al., 2019). Theorists have proposed that different dimensions or variants of narcissism can be grouped into narcissistic grandiosity and narcissistic vulnerability. The failure to differentiate between grandiose (overtly immodest, entitled, self-centered, and domineering) and vulnerable (self-centered, neurotic, distrustful, and introverted) presentations of narcissism has further contributed to controversy (Miller et al., 2018). The existing inventories of narcissism conflict on whether they assess grandiose, vulnerable narcissism, or both. They also conflict on the level to which they adequately assess these dimensions.

Professional Beliefs about NPD

I believe that NPD differs from narcissism, and the two should be distinguished in the clinical setting. Narcissism is a personality element that occurs in various disorders, but it is central to NPD. I would diagnose a person as having a narcissistic personality if they are haughty, feel superior to others, are obsessed with themselves and admiration, and exhibit a significant lack of empathy (Miller et al., 2021; Day et al., 2022). Patients with NPD have difficulties in identity and emotion regulation within the perspective of interpersonal relationships (Crowe et al., 2019). Words that can be used to describe people with narcissistic grandiosity-related presentations are overt, thick-skinned, spiteful, insensible, manipulative, thick-skinned, arrogant, and psychopathic.

Maintaining a Therapeutic Relationship with a Patient with NPD

Therapists working with patients with NPD often face various challenges because of the complex nature of the disorder’s intra and interpersonal processes. Zalman et al. (2019) explain that narcissistic patients can be less inclined to share their vulnerability and admit their need for other people. Thus, it is important to not only concentrate on the explicit aspects but also focus on more inherent aspects of the therapeutic alliance. Furthermore, the therapist should set clear boundaries with the patient, create a less-threatening atmosphere, and exhibit non-pathologic coping skills to the patient.

Ethical and Legal Considerations Related to NPD

            Ethical considerations when handling patients with NPD should include preventing any harm to the pat

 Controversy Associated with Personality and Paraphilic Disorders

Controversy Associated with Personality and Paraphilic Disorders

ient, whether physical or psychological. The practitioner should create an environment where patients can admit they have made a mistake while maintaining their overall positive self-image (Bolsinger et al., 2020). This communicates to the patients that it is acceptable to make mistakes and that they do not have to threaten their self-worth.


Controversies surrounding NPD are based on the definition of grandiose and vulnerable features, the universal description of NPD, and the differences between normal and pathological narcissism. The therapist should pay attention to the inherent aspects of the therapeutic alliance. Besides, the therapist should create a psychologically safe environment for the patient.




Bolsinger, J., Jaeger, M., Hoff, P., & Theodoridou, A. (2020). Challenges and Opportunities in Building and Maintaining a Good Therapeutic Relationship in Acute Psychiatric Settings: A Narrative Review. Frontiers in psychiatrypp. 10, 965.

Crowe, M. L., Lynam, D. R., Campbell, W. K., & Miller, J. D. (2019). Exploring the structure of narcissism: Toward an integrated solution. Journal of Personality, 87(6), 1151–1169.

Day, N. J. S., Townsend, M. L., & Grenyer, B. F. S. (2022). Living with pathological narcissism: core conflictual relational themes within intimate relationships. BMC psychiatry, 22(1), 30.

Miller, J. D., Lynam, D. R., Hyatt, C. S., & Campbell, W. K. (2018). Controversies in Narcissism. Annual Review of Clinical Psychology, 13(1), 291–315. doi:10.1146/annurev-clinpsy-032816-045244

Miller, J. D., Back, M. D., Lynam, D. R., & Wright, A. G. (2021). Narcissism today: What we know and what we need to learn. Current Directions in Psychological Science30(6), 519–525.

Zalman, H., Doorn, K. A., & Eubanks, C. F. (2019). Alliance challenges in the treatment of a narcissistic patient: the case of Alex. Research in psychotherapy (Milano)22(2), 351.