Controversy Associated with Personality and Paraphilic Disorders
Narcissistic Personality Disorder
Narcissistic Personality Disorder (NPD) is defined in the DSM5 as a persistent pattern of grandiosity, need for admiration, and impaired empathy. Individuals with NPD often present with exaggerated self-importance, preoccupation with success or power, and a tendency to exploit others in relationships. At the same time, research shows that many patients experience underlying vulnerability, shame, and unstable self-esteem that is easily threatened by criticism or perceived rejection (Caligor et al., 2022). This dual presentation of grandiosity and fragility makes assessment complex and requires careful evaluation by the PMHNP. NPD affects social functioning, occupational performance, and interpersonal stability, often leading to conflict and difficulty maintaining long-term relationships. These features highlight the need for structured and consistent approaches in practice.
Controversy surrounding NPD focuses on diagnostic validity, overlap with normal personality traits, and clinical bias. One major issue involves the difficulty in distinguishing between adaptive narcissistic traits such as confidence and pathological narcissism that causes impairment. This creates inconsistency in diagnosis across providers and settings (Ronningstam, 2023). Another concern is overlap with other personality disorders, especially borderline and antisocial personality disorders, which complicates accurate classification and treatment planning. In addition, stigma plays a major role, as patients with NPD are often labeled as difficult or resistant to treatment, which may reduce willingness among PMHNPs to engage in care. Some scholars argue that the categorical model in the DSM-5-TR does not fully capture the dimensional nature of personality pathology, leading to ongoing debate in psychiatric literature. These issues continue to influence how NPD is diagnosed and managed in practice.
From a professional perspective, NPD should be approached as a disorder of self-regulation and interpersonal functioning rather than a fixed personality flaw. Many individuals with NPD have developmental histories that include inconsistent validation, trauma, or attachment disruptions, which contribute to maladaptive coping strategies (Kealy & Ogrodniczuk, 2024). Treatment should focus on improving emotional regulation, increasing empathy, and developing stable self-esteem. Evidence supports the use of psychodynamic therapy, schema therapy, and cognitive behavioral therapy to address maladaptive beliefs and relational patterns (Caligor et al., 2022). A structured and consistent approach by the PMHNP allows gradual development of insight and behavioral change. The PMHNP should avoid labeling and instead focus on specific behaviors and treatment goals to improve engagement and reduce resistance. This approach supports long-term therapeutic outcomes.
Maintaining a therapeutic relationship with individuals who have narcissistic personality disorder requires clear structure, consistency, and emotional neutrality. The PMHNP should establish firm boundaries early in treatment and reinforce them consistently to prevent manipulation or boundary testing. A neutral and respectful tone helps reduce defensiveness and supports patient engagement. It is important to validate the patient’s emotional experience without reinforcing grandiosity or entitlement. Focusing on specific behaviors rather than personality traits allows more productive discussion and reduces conflict. Gradual development of insight should be encouraged through reflective questioning and structured interventions such as cognitive behavioral techniques. The PMHNP must also monitor countertransference, as strong emotional reactions can affect clinical judgment (Ronningstam, 2023). A consistent and balanced approach supports trust and improves the therapeutic alliance over time.
Ethical and legal considerations related to narcissistic personality disorder focus on maintaining professional boundaries, managing bias, and ensuring appropriate documentation. Patients with NPD may challenge limits or attempt to influence clinical decisions, which requires firm adherence to ethical standards and scope of practice by the PMHNP. Clear communication during informed consent is necessary to address potential misunderstandings or distortions in perception. Confidentiality must be maintained while also managing interpersonal dynamics that may arise in treatment. The PMHNP must remain aware of personal bias and avoid negative labeling, as this can impact quality of care and therapeutic engagement (American Psychiatric Association, 2022). Accurate and detailed documentation is important to support clinical decisions and protect both patient and provider in complex interactions. These considerations guide safe and ethical practice in managing personality disorders.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Caligor, E., Levy, K. N., & Yeomans, F. E. (2022). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 179(5), 321–330. https://doi.org/10.1176/appi.ajp.2021.21010023
Kealy, D., & Ogrodniczuk, J. S. (2024). Treatment approaches for narcissistic personality disorder: Current evidence and future directions. Current Opinion in Psychology, 54, 101707. https://doi.org/10.1016/j.copsyc.2023.101707
Ronningstam, E. (2023). Narcissistic personality disorder: A clinical perspective. Journal of Personality Disorders, 37(2), 145–160. https://doi.org/10.1521/pedi.2023.37.2.145
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Between 10% and 20% of the population experience personality disorders. They are difficult to treat as individuals with personality disorders are less likely to seek help than individuals with other mental health disorders. Treatment can be challenging as they do not see their symptoms as painful to themselves or others.
Paraphilic disorders are far more common in men than in women, and generally quite chronic, lasting at least two years. Treatment of these disorders usually involves both psychotherapeutic and pharmacologic treatments.
In this Assignment, you will explore personality and paraphilic disorders in greater detail. You will research potentially controversial elements of the diagnosis and/or treatment and explain ethical and legal considerations when working with these disorders.
To Prepare
- Review this week’s Learning Resources and consider the insights they provide on assessing, diagnosing, and treating personality and paraphilic disorders.
- Select a specific personality or paraphilic disorder from the DSM-5-TR to use for this Assignment.
- Use the Walden Library to investigate your chosen disorder further, including controversial aspects of the disorder, maintaining the therapeutic relationship, and ethical and legal considerations.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
The Assignment
In 2–3 pages:
- Explain the controversy that surrounds your selected disorder.
- Explain your professional beliefs about this disorder, supporting your rationale with at least three scholarly references from the literature.
- Explain strategies for maintaining the therapeutic relationship with a patient that may present with this disorder.
- Finally, explain ethical and legal considerations related to this disorder that you need to bring to your practice and why they are important.
By Day 7 of Week 7
Submit your Assignment.
submission information
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- To submit your completed assignment, save your Assignment as WK7Assgn_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
NRNP_6675_Week7_Assignment_Rubric
| NRNP_6675_Week7_Assignment_Rubric | ||
| Criteria | Ratings | Pts |
| This criterion is linked to a Learning OutcomeIn 2–3 pages, address the following: • Explain the controversy that surrounds your selected personality or paraphilic disorder. | 15 to >13.0 ptsExcellent 90%–100%The response includes an accurate and concise explanation of the controversy within the field related to the disorder.
13 to >11.0 ptsGood 80%–89%The response includes an accurate explanation of the controversy within the field related to the disorder. 11 to >10.0 ptsFair 70%–79%The response includes a somewhat vague or inaccurate explanation of the controversy within the field related to the disorder. 10 to >0 ptsPoor 0%–69%The response includes a vague or inaccurate explanation of the controversy within the field related to the disorder. Or the response is missing. |
15 pts |
| This criterion is linked to a Learning Outcome• Explain your professional beliefs about your selected disorder, supporting your rationale with at least three scholarly references from the literature. | 25 to >22.0 ptsExcellent 90%–100%The response includes a thorough and well-organized explanation of the student’s professional beliefs about the disorder. Rationale demonstrates critical thinking and is strongly supported with three scholarly references.
22 to >19.0 ptsGood 80%–89%The response includes a well-organized explanation of the student’s professional beliefs about the disorder. Rationale is clear and appropriately supported with three scholarly references. 19 to >17.0 ptsFair 70%–79%The response includes a somewhat vague explanation of the student’s professional beliefs about the disorder. Rationale is somewhat unclear and references either provide weak support for the rationale or are not scholarly/current. 17 to >0 ptsPoor 0%–69%The response includes a vague explanation of the student’s professional beliefs about the disorder. Rationale is unclear and references are inappropriate. Or the response is missing. |
25 pts |
| This criterion is linked to a Learning Outcome• Explain strategies for maintaining the therapeutic relationship with a client that may present with the disorder. | 30 to >26.0 ptsExcellent 90%–100%The response includes an accurate and concise explanation of strategies for maintaining the therapeutic relationship with a client that may present with the disorder.
26 to >23.0 ptsGood 80%–89%The response includes an accurate explanation of strategies for maintaining the therapeutic relationship with a client that may present with the disorder. 23 to >20.0 ptsFair 70%–79%The response includes a somewhat vague or incomplete explanation of strategies for maintaining the therapeutic relationship with a client that may present with the disorder. 20 to >0 ptsPoor 0%–69%The response includes a vague or inaccurate explanation of strategies for maintaining the therapeutic relationship with a client that may present with the disorder. Or the response is missing. |
30 pts |
| This criterion is linked to a Learning Outcome• Finally, explain ethical and legal considerations related to the disorder that you need to bring to your practice and why they are important. | 15 to >13.0 ptsExcellent 90%–100%The response includes an accurate and concise explanation of ethical and legal considerations related to the disorder that are important to clinical practice and why they are important.
13 to >11.0 ptsGood 80%–89%The response includes an accurate explanation of ethical and legal considerations related to the disorder that are important to clinical practice and why they are important. 11 to >10.0 ptsFair 70%–79%The response includes a somewhat vague or incomplete explanation of ethical and legal considerations related to the disorder that are important to clinical practice and why they are important. 10 to >0 ptsPoor 0%–69%The response includes a vague and inaccurate explanation of ethical and legal considerations related to the disorder that are important to clinical practice and why they are important. Or, response is missing. |
15 pts |
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. | 5 to >4.0 ptsExcellent 90%–100%Paragraphs and sentences follow writing standards for flow, continuity, and clarity…. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.5 ptsGood 80%–89%Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time…. Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. 3.5 to >3.0 ptsFair 70%–79%Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time…. Purpose, introduction, and conclusion of the assignment are vague or off topic. 3 to >0 ptsPoor 0%–69%Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time…. No purpose statement, introduction, or conclusion were provided. |
5 pts |
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation | 5 to >4.0 ptsExcellent 90%–100%Uses correct grammar, spelling, and punctuation with no errors
4 to >3.5 ptsGood 80%–89%Contains 1-2 grammar, spelling, and punctuation errors 3.5 to >3.0 ptsFair 70%–79%Contains 3-4 grammar, spelling, and punctuation errors 3 to >0 ptsPoor 0%–69%Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding |
5 pts |
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. | 5 to >4.0 ptsExcellent 90%–100%Uses correct APA format with no errors
4 to >3.5 ptsGood 80%–89%Contains 1-2 APA format errors 3.5 to >3.0 ptsFair 70%–79%Contains 3-4 APA format errors 3 to >0 ptsPoor 0%–69%Contains five or more APA format errors |
5 pts |
Total Points: 100
Learning Resources
Required Readings
- National Institute for Health and Care Excellence: NICE Guidelines. (2010). Antisocial personality disorder: Prevention and management Links to an external site..
https://www.nice.org.uk/guidance/cg77 - Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
- Chapter 19 “Personality Disorders”
- Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
- Chapter 67, “Disorders of Personality”
- Chapter 68, “Developmental Risk for Psychopathy”
- Chapter 69, “Gender Dysphoria and Paraphilic Sexual Disorders” (pp. 988–993 only)
- Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual . Springer Publishing Company.
- Chapter 14, “Personality Disorders”
Required Media
- Buchanan, N. T. (2020, April 13). Lecture 14 part 3: Paraphilic disorders Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=ykkMo9t0bxs
- MDedge. (2020, January 22). Personality disorders with Dr. Frank Yeomans Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=ESQIDslCX_s