Narcissistic Personality Style

Style, Disorder, and the Space Between

Self-esteem worries are universal, so this is the style most easily mistaken for a passing reaction. McWilliams warns that narcissistic personality is over-diagnosed, especially by psychodynamic clinicians. To count as a character pattern, the preoccupation has to be longstanding, automatic, and present whatever the situation (McWilliams, 2011, p. 192). Kohut and Wolf called the bragging, idealizing, or hypercritical behavior of people whose identity is under strain a “secondary narcissistic disturbance,” not a narcissistic character. McWilliams’ example is medical and psychotherapy training, which can make capable adults feel like incompetent children (McWilliams, 2011, p. 192). The PDM-3 adds that an older person who proudly mentions their age or memory is not showing a personality disorder, especially if they weren’t like this earlier in life. Aging can raise realistic needs for reassurance (Del Corno & Plotkin, 2026, p. 944).

Across the levels of organization, the style looks roughly like this:

• Healthy. Self-esteem still leans on outside recognition but also answers to an internal voice, which is what McWilliams hopes therapy can strengthen (McWilliams, 1999, p. 174). In adolescents at the healthier pole, the focus is realistic pride in accomplishment (Tanzilli & Sharp, 2026, p. 503).
• Neurotic. The person is socially appropriate and often successful, fits reasonably well into family and work, and is “somewhat deficient in the capacity for intimacy” (McWilliams & Shedler, 2026, p. 688).
• Borderline. A grandiose self-presentation may hide identity diffusion and a lack of inner-directed morality, and behavior can be harmful to others. Kernberg’s most severe form, “malignant narcissism,” adds sadistic aggression and sits on a continuum with psychopathy (McWilliams & Shedler, 2026, p. 688). Researchers working with Kernberg describe it as grandiosity combined with paranoid, psychopathic, and sadistic features (Lenzenweger et al., 2018).
• Psychotic. As early as 1913, Ernest Jones placed the grandiose type on a continuum running all the way from normal to psychotic, where grandiosity can become a delusion (McWilliams, 2011, p. 178).

Kernberg also sorted narcissistic people by how well they function socially. Some are gifted and so well rewarded that they never seek help. A larger group comes to treatment for trouble sustaining relationships and a nagging aimlessness despite success. A third group functions at an overtly borderline level (as summarized in Akhtar, 1989/2023, p. 53).

Signs that a style has become a disorder include rigidity (one way of protecting self-worth, used everywhere), pervasiveness across work, love, and friendship, real suffering or harm to others, and very little ability to step back and see the pattern. The PDM-3 reserves “disorder” for a degree of extremity or rigidity that causes significant dysfunction, limitation, or suffering to self or others (McWilliams & Shedler, 2026, p. 653). It also notes that longstanding personality patterns can be as invisible to their owner as water to a fish (McWilliams & Shedler, 2026, p. 654).

The DSM-5-TR diagnosis, narcissistic personality disorder, requires a pervasive pattern of grandiosity, need for admiration, and lack of empathy, shown by at least five of nine criteria (Mitra et al., 2024). Psychodynamic writers point out that these criteria describe only the grandiose version. They leave out the many people who arrive feeling shy, ashamed, and empty while privately nursing fantasies of the recognition they believe they deserve (McWilliams & Shedler, 2026, p. 688). ICD-11 has no narcissistic category at all. It rates personality disorder by severity, and entitlement, grandiosity, and expecting admiration appear under its “Dissociality” trait domain (Bach & First, 2018).

Inner World

The central tension is between a grandiose self and a depleted one. Kernberg described these as opposite states, all-good and all-bad, and McWilliams adds that feeling “good enough” is simply not one of the person’s inner categories (McWilliams, 2011, p. 185). People with this style often sense that their identity is too fragile to hold up under strain. They fear suddenly feeling like nobody rather than somebody, and that fear may surface as worry about their health (McWilliams, 2011, p. 185).

The signature emotions are shame and envy (McWilliams, 2011, p. 180). Early analysts often mistook shame for guilt and made guilt-based interpretations that these patients experienced as unempathic. McWilliams separates the two this way: guilt is the conviction that one has done wrong, judged by an inner critic, while shame is the sense of being seen as bad or wrong, with the audience outside the self (McWilliams, 2011, p. 180). Envy follows from feeling deficient. If you seem to have what I lack, I may try to spoil it by scorning it (McWilliams, 2011, p. 180).

Two experiences are especially hard: remorse and gratitude. Remorse admits a flaw, and gratitude admits a need, so both threaten a self built on having neither. Sincere apologies and heartfelt thanks may be avoided or watered down, to the great cost of the person’s relationships (McWilliams, 2011, p. 185).

Little is known about temperament here. McWilliams knew of no research on constitutional contributions (McWilliams, 2011, p. 179). Two clinical hypotheses stand out. Alice Miller suggested that unusually intuitive children, attuned to what their caregivers feel without words, are more likely to be used to prop up a parent’s self-esteem. Kernberg proposed that some grandiose patients may be born with strong aggression, or with little tolerance for anxiety about it (McWilliams, 2011, pp. 179–180).

Typical pathogenic beliefs, put in plain words, include: Needing anyone proves I’m defective. If my real feelings showed, I would be rejected or humiliated. Things are either the best or worthless. (McWilliams, 2011, pp. 180–183, 191; Tanzilli & Sharp, 2026, p. 502). Mapped onto the PDM-3 M axis (our mapping, not the manual’s), the hardest-hit capacity is self-esteem regulation. McWilliams’ shorthand for this style’s self-esteem is that it basks in validation and admiration from others. One goal of therapy is to make the person responsive to an internal voice as well (McWilliams, 1999, p. 174).

Defenses

People with this style use many defenses, but McWilliams names two as fundamental: idealization and devaluation. They work as a pair. When the self is idealized, others are devalued, and the reverse (McWilliams, 2011, p. 180). Either side can point either way, which gives four common moves:

• Inflating the self and looking down on others.
• Idealizing someone else, such as a mentor, partner, or hero, and feeling bigger by association. When the idol shows a flaw, they get knocked off the pedestal (McWilliams, 2011, p. 182).
• Devaluing the self in a depleted, depressed state, while still privately holding a grandiose picture of who one ought to be.
• Ranking: sizing up every choice by comparative prestige, such as the “best” doctor or the “finest” school, even when the practical pros and cons point elsewhere (McWilliams, 2011, pp. 180–181).

Perfectionism is the trap at the center. The person sets unrealistic ideals and then either believes they have met them (the grandiose outcome) or feels basically defective for falling short (the depressive outcome). Since no one is perfect, the strategy is bound to fail (McWilliams, 2011, pp. 181–182). Kernberg emphasized defenses against envy, especially devaluation, omnipotent control, and narcissistic withdrawal (as summarized in Akhtar, 1989/2023, p. 52). The PDM-3 lists omnipotence, idealization of self, devaluation of others, splitting, and projection as the pillars of the emerging adolescent version (Tanzilli & Sharp, 2026, p. 502). Because mistakes feel so exposing, people may also use language that quietly disowns responsibility, such as “Mistakes were made” (McWilliams, 2011, p. 191).

On the adaptive side, ambition and high standards can serve real achievement. Kernberg noted that some talented narcissistic people reach outstanding social success, though he called work done mainly to win admiration “pseudosublimatory,” as distinct from work that is satisfying in itself (as summarized in Akhtar, 1989/2023, pp. 52–53).

Relationships

Self psychologists call the people who prop up our self-esteem “selfobjects.” Everyone has and needs them. McWilliams adds that reality and morality require us to recognize others as people in their own right, with their own needs, not only as sources of support (McWilliams, 2011, p. 182). In narcissistic psychology, the need for selfobjects is so great that other aspects of relationship fade. Her summary is stark: the need for others is deep, but the love for them is shallow, and the greatest cost of the style is “a stunted capacity to love” (McWilliams, 2011, p. 183). The result, McWilliams says, is confusing messages to friends and family (McWilliams, 2011, p. 183). The PDM-3 prototype describes a tendency to treat others mainly as an audience (McWilliams & Shedler, 2026, p. 690).

Theories of origin center on being valued for a function rather than for oneself. McWilliams describes children treated as “narcissistic extensions,” loved on the unspoken condition that they serve a parent’s self-esteem. This encourages what Winnicott called a “false self,” a presentation of whatever has proved acceptable (McWilliams, 2011, p. 183). An atmosphere of constant evaluation can do similar harm even when the verdict is always positive. A child who is perpetually praised still knows they are being judged and may grow up quietly feeling like a fraud (McWilliams, 2011, p. 184). McWilliams also summarizes Fiscalini’s three precursors, the shamed child, the spoiled child, and the special child, and notes that parents whose own options were cut short by war, persecution, or other disaster may signal that a child should live the life they never had. Such children often grow up with some identity confusion and a vague sense of shame and emptiness, and the message that “you can have it all” is a crippling inheritance, because no one can (McWilliams, 2011, pp. 184–185). Drawing on Kohut, the PDM-3 traces narcissistic problems to parental failures of empathy, which can include excessive praise that spares the child the “optimal frustration” needed to learn realistic limits (Tanzilli & Sharp, 2026, p. 502). Attachment research by Diamond and colleagues links narcissism to insecure attachment that may stem from confusing, unpredictable early relationships full of hidden agendas (McWilliams & Shedler, 2026, p. 689). The PDM-3 grants that mass culture and social media can intensify narcissistic preoccupations in adolescents, but notes that most scholars locate the origins in early development (Tanzilli & Sharp, 2026, p. 502).

These are theories, not accusations. McWilliams stresses that most parents combine narcissistic needs with real empathy, that children enjoy making parents proud in moderation, and that parents need not have narcissistic personalities themselves for a child to develop this style (McWilliams, 2011, pp. 183–184).

Change often becomes possible later in life. Both McWilliams and the PDM-3 note that people with this style tend to seek help, and to benefit, in midlife or later, when fantasies of limitless success have not come true and the emptiness of the old strategy is harder to ignore (McWilliams, 1999, p. 177; McWilliams & Shedler, 2026, p. 690).

In Therapy

Transference means the feelings and expectations a person brings into the therapy relationship from earlier relationships. Countertransference means the therapist’s own emotional reactions to the client, which can be a useful source of information.

With narcissistic clients, transference often looks at first like a lack of interest in the relationship. Questions about how the client feels toward the therapist may seem pointless or irritating, even though the client may strongly idealize or devalue the therapist. Those reactions feel so obviously justified to the client that they can’t be explored at first (McWilliams, 2011, pp. 186–187). Self psychologists describe “selfobject transferences,” in which the therapist is used to hold up the client’s self-esteem. In mirroring transferences the client needs admiration. In idealizing transferences the client needs to merge with someone powerful. In twinship transferences the client needs someone reassuringly similar (McWilliams, 2011, pp. 187–188; Tanzilli & Sharp, 2026, p. 503).

Countertransference is often quiet and uncomfortable. Therapists report boredom, irritation, drowsiness, and a sense that nothing is happening. McWilliams calls the feeling of having been made invisible as a real person diagnostic of a likely narcissistic dynamic (McWilliams, 2011, p. 187). With an idealizing client, a therapist may briefly feel a grandiose glow, as if the two had formed a mutual admiration society, but McWilliams finds this rarely convincing or lasting (McWilliams, 2011, p. 187). The PDM-3 adds distraction, impatience, and, when the client’s wounds show, parental feelings (McWilliams & Shedler, 2026, p. 689). With adolescents, reactions depend on the subtype: grandiose teens tend to evoke irritation and a sense of being dismissed, fragile teens evoke protectiveness and sometimes overinvolvement, and high-functioning/exhibitionistic teens evoke more positive feelings (Tanzilli & Sharp, 2026, p. 503). Understood this way, these reactions become information about how the client experiences others, not proof that the therapist is failing (McWilliams, 2011, pp. 187–188).

What tends to help: patience, since nobody changes this pattern quickly (McWilliams, 2011, p. 188). It also helps when the therapist is matter-of-fact about their own imperfection. Kohut showed how much it matters to acknowledge empathic failures. An apology confirms the client’s real feelings and models keeping self-esteem while admitting a mistake. The apology should not come with so much self-reproach that it suggests mistakes ought to be rare (McWilliams, 2011, p. 190). Interventions are framed with constant awareness of the shame underneath even the most arrogant surface (McWilliams, 2011, p. 190). Gentle questions such as whether the client made their needs explicit can open the shameful belief that needing anyone is a defect (McWilliams, 2011, p. 191). Clinicians often shift tone, being more soothing with depleted clients and more confronting with entitled ones, who may not respect a therapist who doesn’t stand up to them (McWilliams, 2004, pp. 144–145). Progress tends to be slow, but the PDM-3 stresses that any improvement matters, both to the client and to the people in their life (McWilliams & Shedler, 2026, p. 690).

Common sticking points: some clients arrive expecting therapy to perfect the self rather than to understand it (McWilliams, 2011, p. 181). Envy can slow progress, because getting better would admit needing the therapist’s help, and idealization can pressure the therapist to be brilliant, though not so brilliant as to outshine the client (McWilliams & Shedler, 2026, pp. 689–690). Clients who are not in a position to act superior may instead ask the therapist to teach them how to be “normal” or “popular” (McWilliams & Shedler, 2026, pp. 688–689). Early analysts thought these clients untreatable partly because many broke off even long therapies abruptly when their feelings were hurt (McWilliams, 2011, p. 191).

What tends to backfire: questions about who the therapist is to the client, and interpretations along the lines of “Maybe you’re experiencing me as like your mother right now,” which tend to fall flat or seem like pointless distractions (McWilliams, 2011, p. 191). So does either unempathic confrontation or joining the client in blaming everyone else (McWilliams, 2011, p. 191). Mistaking the style for obsessive-compulsive and treating it as a guilt-and-control problem also tends to fail (McWilliams, 2011, pp. 193–194). Therapists are often surprised to learn that a client who seems to dismiss them in sessions quotes them admiringly elsewhere (McWilliams, 2011, p. 192).

Variations

Again and again, clinicians have described two faces of narcissism under different names (McWilliams, 2011, pp. 178–179; McWilliams & Shedler, 2026, p. 688):

• Oblivious versus hypervigilant (Gabbard, 1989). Gabbard placed these at the two ends of a continuum and noted that they produce different transference and countertransference patterns.
• Overt versus covert or “shy” (Akhtar). Akhtar described a person who is overtly grandiose, articulate, and seductive but covertly doubt-ridden, envious, and bored (Akhtar, 1989/2023, p. 66).
• Exhibitionistic versus “closet” (Masterson).
• Thick-skinned versus thin-skinned (Rosenfeld, 1987). Bateman (1998) observed that patients may move between the two positions.
• Grandiose versus vulnerable (Pincus and colleagues). Pincus, Cain, and Wright (2014) treat these as two themes that often co-occur in the same person, each expressed openly or hidden.

Using the SWAP, Russ, Shedler, Bradley, and Westen (2008) found three empirical subtypes: grandiose/malignant, fragile, and high-functioning/exhibitionistic. They also found that interpersonal vulnerability and emotional distress were core features that the DSM-IV criteria left out. The PDC-3 form lists overt, covert, and malignant subtypes (Gordon & Bornstein, 2025). Earlier, Kohut and Wolf described mirror-hungry, ideal-hungry, alter-ego, merger-hungry, and contact-shunning personalities, and they counted the first three as variants of normal personality (as summarized in Akhtar, 1989/2023, pp. 55–56). McWilliams also mentions Bursten’s craving, paranoid, manipulative, and phallic-narcissistic subvarieties, and Pharis’s “virtuous” type, who accomplishes great things but quietly lets an associate take the blame for mistakes (McWilliams, 2011, pp. 178–179).

Common blends include narcissistic features with depressive, obsessive-compulsive, hysterical-histrionic, paranoid, and, at the severe end, psychopathic dynamics. Akhtar noticed a midlife “crossover” in which some narcissistic people withdraw and come to resemble schizoid people, while some gifted schizoid people become more openly ambitious (Akhtar, 1987/2023, pp. 21–22). In old age, arrogance may turn into stubbornness, and dependence on others may push the person toward the depleted form. Because so much rests on protecting one’s image, the bodily changes of aging can be especially hard to bear, and comparisons with one’s younger self, or with younger people, can bring bitterness, shame, envy, and depression (Del Corno & Plotkin, 2026, p. 945).

How Different Thinkers See It

Freud and the early analysts

Freud first used the word in a 1910 footnote and developed it in “On Narcissism” (1914), which introduced primary and secondary narcissism and tied the ego ideal to narcissism (Akhtar, 1989/2023, p. 47). He made narcissism universal: not only a perversion but the libidinal complement of the instinct for self-preservation (as discussed in Rees, 2022). His 1931 “narcissistic type” stressed independence, ready aggressiveness, and a capacity for leadership (Akhtar, 1989/2023, p. 48). Alfred Adler stressed the opposite emphasis: narcissism as compensation for inferiority. McWilliams sees that disagreement still running through later debates (McWilliams, 2011, p. 186). Object relations theorists later rejected the idea of a primary narcissism in which the infant loves itself before anyone else. They read narcissistic problems as compensation for early disappointment in relationships instead (McWilliams, 2011, p. 177).

Wilhelm Reich

Reich’s “phallic-narcissistic character” (1933) was self-assured, arrogant, and energetic, and would usually “anticipate any impending attack with an attack of his own.” Reich saw this as warding off a deep feeling of inferiority (McWilliams, 2011, p. 178; Akhtar, 1989/2023, p. 49). The PDM-3 notes that the DSM criteria still describe essentially this grandiose version (McWilliams & Shedler, 2026, p. 688).

Heinz Kohut and self psychology

Kohut (1971, 1977, 1984) saw pathological narcissism developmentally, as normal growth that stalled when needs to idealize and be mirrored were not met. McWilliams’ image is a plant stunted by too little water and sun (McWilliams, 2011, pp. 188–189). In treatment, Kohut stressed empathic attunement, patience with idealization, and attention to the therapist’s inevitable empathic failures (McWilliams & Shedler, 2026, p. 689). He first treated the twinship or alter-ego transference as one form of mirroring, and in 1984 he made it a type of its own (Oppenheimer, 2005).

Otto Kernberg and object relations

Kernberg (1975, 1984) saw the problem structurally: a cohesive but pathological “grandiose self” that hides identity diffusion and is powered by envy and defenses against dependence (Akhtar, 1989/2023, pp. 52–53; Tanzilli & Sharp, 2026, p. 502). In McWilliams’ metaphor, the plant has mutated into a hybrid and needs pruning, not just water (McWilliams, 2011, p. 189). Kernberg recommended tactful but systematic confrontation of grandiosity and of defenses against envy, shame, and healthy dependency (McWilliams, 2011, p. 189; McWilliams & Shedler, 2026, p. 689). He suggested that Kohut’s approach worked as a form of supportive therapy (McWilliams, 2011, p. 189).

The PDM-3 points out that the two men saw different patients. Kohut mostly treated idealizing psychoanalytic candidates. Kernberg treated devaluing, hospitalized patients. Most contemporary clinicians combine the two approaches, confronting defenses when they are prominent and attuning to hurt when it is accessible (McWilliams & Shedler, 2026, p. 689). McWilliams describes the chicken-and-egg question of whether the grandiose or the depleted state comes first as possibly unanswerable (McWilliams, 2011, p. 186).

Herbert Rosenfeld and the British Kleinians

Rosenfeld emphasized omnipotence and the denial of separateness and dependence. He described a more malignant situation in which destructive parts of the self are idealized and offered love is attacked to preserve superiority (as summarized in Akhtar, 1989/2023, pp. 60–61). His thick-skinned/thin-skinned distinction (1987) is still widely used.

Empirical and diagnostic approaches

Research has largely confirmed the clinicians’ two faces. Cain, Pincus, and Ansell (2008) found that clinical theory, personality psychology, and psychiatry all point to two themes, grandiosity and vulnerability, and that the DSM’s emphasis on overt grandiosity weakens the diagnosis. The SWAP findings of Russ and colleagues (2008) and the empirical prototypes of Westen, Shedler, Bradley, and DeFife (2012) now underpin the PDM-3 descriptions. The DSM-5 alternative model keeps narcissistic personality disorder and defines it through impaired functioning plus the traits of grandiosity and attention seeking (Gori & Topino, 2025).

Examples

The Harvard campaign

McWilliams describes a mother determined that her son attend the “best” college. When he was admitted to several excellent schools but not Harvard, she was devastated. Throughout his freshman year at Princeton, where he was thriving, she kept pressing Harvard to accept him as a transfer, against what she knew about his field and his social life. McWilliams stresses that this woman did not have a narcissistic personality disorder. In this one area she was using her son as a narcissistic extension, driven by a belief that her own life would have been transformed if she had gone to Radcliffe. It is a clear picture of ranking at work in someone who is not characterologically narcissistic.

Nancy McWilliams, Psychoanalytic Diagnosis (2nd ed., 2011), p. 181

Richard

A PDM-3 illustration describes Richard, a 15-year-old brought to therapy because of trouble at school; his parents had gone through a bitter divorce years earlier. He presented himself as a “friendly and popular kind of guy.” The assessing clinician saw this image as covering inadequacy, loneliness, and a sense of having been dealt a bad hand. He kept constantly busy and avoided thinking. He reacted with rage when he felt displaced in his mother’s life and seemed to serve as an extension of her self-esteem. He was assessed as having an emerging narcissistic style at a borderline level of organization, relying on omnipotence and devaluation.

Vittorio Lingiardi & Nancy McWilliams (Eds.), PDM-3 Online Supplement (2026), pp. 104–109

Narcissus (myth)

The style is named for the youth of Greek myth who fell in love with his own reflection in a pool. McWilliams notes that Freud borrowed the term from this myth, and her retelling ends not with vanity but with Narcissus dying of a longing that his image could never satisfy.

Nancy McWilliams, Psychoanalytic Diagnosis (2nd ed., 2011), p. 176

How It Differs From Look-Alikes

A narcissistic reaction

Anyone whose identity and confidence are under strain, such as a trainee in a demanding program, can sound arrogant, critical, or idealizing for a while. A narcissistic character shows these patterns over a long time and across situations, and history and the feel of the relationship reveal it (McWilliams, 2011, pp. 192–193).

Depressive personality

Both can look depressed. McWilliams’ shorthand: narcissistically depressed people feel empty and lack a substantial self, while introjectively depressive people feel full of harsh, critical inner voices and feel that the self is real but bad (McWilliams, 2011, p. 193).

Obsessive-compulsive personality

Perfectionism and attention to detail can look obsessive. Narcissistic clients are more empty than angry, and therapy built around guilt and control struggles leaves them feeling misunderstood (McWilliams, 2011, pp. 193–194).

Hysterical-histrionic personality

Both may be exhibitionistic and swing from idealization to devaluation. In hysterical-histrionic people these concerns are tied to gender, fueled more by anxiety than shame, and limited to certain areas. Outside those areas, they are warm and far from empty (McWilliams, 2011, p. 194; McWilliams & Shedler, 2026, p. 686).

Psychopathic personality

The two lie on a continuum through malignant narcissism. Akhtar notes that narcissistic people may act antisocially at times but lack the consistent, calculated disregard for social norms, and usually keep the capacity for steady work (Akhtar, 1989/2023, p. 71). McWilliams notes that Kohutian empathy tends to be scorned by psychopathic people (McWilliams, 2011, p. 193).

Paranoid personality

Both can show cold grandiosity, envy, and touchiness about criticism. Paranoid people lack the attention-seeking charm of people with narcissistic styles and are pervasively mistrustful. Narcissistic people fear exposure of their own inadequacy, while paranoid people fear other people’s malevolence (Akhtar, 1989/2023, pp. 70–71; McWilliams, 2011, p. 217).

History

Havelock Ellis used the phrase “Narcissus-like” in 1898, and Paul Näcke coined “narcissism” the following year for treating one’s own body as a sexual object (Rees, 2022). Freud gave the term its psychological breadth in 1914 (Akhtar, 1989/2023, p. 47). Ernest Jones’s 1913 essay on the “God complex” and Reich’s phallic-narcissistic character (1933) described the grandiose type before it had a formal name (Akhtar, 1989/2023, pp. 48–49).

Self-esteem moved to the center of psychoanalysis in the 1970s. Clinicians were seeing more patients who complained of emptiness and meaninglessness rather than classic inner conflict (McWilliams, 1999, pp. 161–162). Kohut’s The Analysis of the Self (1971) and Kernberg’s Borderline Conditions and Pathological Narcissism (1975) launched a long debate over deficit versus structure (McWilliams, 2011, pp. 188, 195). Social critics argued that modern mass culture, with its mobility and emphasis on image, encourages narcissistic concerns (McWilliams, 2011, p. 177).

Narcissistic personality disorder entered the DSM in 1980 with DSM-III. Clinicians influenced by Kohut, Kernberg, and Millon had made the concept widely used (Yakeley, 2018). ICD-10 did not list it as a specific personality disorder; narcissistic personality appeared only under its “other specific” category (Yakeley, 2018; Bach & First, 2018). During DSM-5 development, the work group’s proposal dropped it as a separate type, which prompted defenses of the diagnosis such as Ronningstam (2011). It survived in the main manual and in the alternative model in Section III (Gori & Topino, 2025), where it is one of six types kept (Pesic et al., 2026). ICD-11 abolished personality disorder types altogether (Pesic et al., 2026).

The empirical turn has mostly vindicated the clinical tradition. Research now agrees that the DSM criteria are too narrow and that vulnerability, shame, and distress belong at the heart of the construct (Russ et al., 2008; Cain et al., 2008).

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