Allen Frances on the NPD Diagnosis

Allen Frances, former chair of Duke University’s Department of Psychiatry, wrote the clinical diagnosis for narcissistic personality disorder (NPD) that first appeared in the third edition of the Diagnostic and Statistical Manual. Afterward, as chair of the DSM-IV task force, Frances found himself at the center of a cultural maelstrom in 2016 when he spoke out against people in the field who were ignoring the Goldwater Rule—which prohibits the diagnosing of individuals you haven’t examined—and attaching a diagnosis of NPD to candidate, and then president, Donald Trump.

“When I wrote the diagnosis,” he says, “it was not an uncommon clinical presentation, and there was lots of debate in our analytic literature about how to treat it. It never occurred to us that it would become of national concern and be put to use by people within our field as a means of deposing a president. I objected to this. Trump is a classic narcissist for the ages, but it needs to be clear to people that diagnoses are a clinical matter and should not be used as a political weapon.”

Though Frances believes we can’t clearly identify whether there’s been an uptick in the diagnosis of NPD since Trump ran for and held the presidency, as many have contended there’s been, he does point to historical precedence showing that, as he says, “diagnosis of disorders does run in fads. The more widely known one becomes, the more primary diagnoses of it you’ll see. Still, there’s no easy fix for NPD, so people aren’t advertising its treatment like they would with other disorders. There’s no pill for this problem. It may be the one thing in this world the drug companies can’t say they can treat.”

Though some in the field have thrown up their hands at working with narcissists, Frances says there can be a spectrum of presentations, and effective work is possible. “Some narcissists might be incapable of insight and change. But others might have some insight and feel terrible about their behavior—think Scrooge, who realizes the error of his ways. We do get patients like that from time to time, and we can try to help them help themselves, and to help others they may’ve hurt.”

He also believes there can be a certain level of treatment effectiveness when a narcissist comes into therapy with someone they’re hurting. “First and foremost, people with severe NPD cause suffering in others, but they don’t recognize that suffering. They themselves suffer only when there’s a narcissistic injury: a partner wants a divorce, or they’re having a medical illness, or a business reversal. Without such an injury, they can go through life with relatively little distress. I find it’s better if you do couples therapy, rather than individual therapy, with highly narcissistic people. With the partner in the room, the narcissist has a better chance of seeing the whole picture.”

Although there’s been some suggestion of late that narcissism is a trauma response and narcissistic traits assist in coping with post-traumatic symptoms, Frances is equivocal when it comes to this claim. “No one has any information about whether NPD is about initial trauma. It used to be considered a response to having an unempathetic mother, but I hate to blame mothers. There may be some genetic disposition, and it’s interesting to consider that what we now think of as a disorder might at one time have been highly adaptive for early communities and societies. There are certainly some strengths with a milder version, and overconfidence hasn’t been weeded out of us as a species despite years of natural selection. It’s only when it gets out of hand that a person becomes a menace to society.”