Narcissistic No More: How Personality Disorders Are Being Redefined

HAMBURG — What is “normal” and what isn’t? This question is constantly being renegotiated in psychology. And sometimes, the boundaries shift, as they are now. What is considered a personality disorder — and what isn’t — is undergoing a fundamental change.

Roughly one in 10 adults lives with a personality disorder. While conditions like depression or anxiety disorders mostly affect how someone feels, a personality disorder influences a person’s self-image and their relationships with others. It causes distress for the person affected or for those around them. Previously, experts drew lines between many different types of personality disorders. Certain personality traits were once classified as pathological. For instance:

• Schizoid personality disorder: marked by a “preference for fantasy” and “solitary behavior.”
• Histrionic personality disorder: marked by “dramatization and a theatrical, exaggerated expression of emotions.”
• Obsessive-compulsive personality disorder: marked by “perfectionism” and “excessive conscientiousness.”
• Narcissistic personality disorder: marked by an “inflated and unfounded sense of self-importance.”
• Anxious-avoidant personality disorder: marked by “hypersensitivity to criticism or rejection” and “avoidance of social contact.”

These disorders were considered long-term and enduring. And they isolated those affected, as if they functioned in an entirely different way, thinking, feeling, and acting unlike the rest of the population. That view is now outdated.

The multitude of diagnoses has been scrapped and removed from the ICD-11 diagnostic manual. The diagnosis “personality disorder” will now be placed on a continuum. This shift is based on the idea that everyone exists somewhere along a spectrum, but that certain individuals cross a specific threshold.

You can think of it like a scale: Some people are highly orderly and conscientious, some only moderately, and others not at all. A few are so meticulous that it seriously disrupts their life. That’s the point at which experts draw the line and label it as pathological.

Having a personality disorder no longer means being fundamentally different. It now means that certain traits are more strongly or less strongly developed compared to others. But what does this shift mean for those affected and for therapy? Does eliminating these categories mark progress?

How the categories came about 

Radical changes in how illness is understood have occurred repeatedly over time. The International Classification of Diseases (ICD), the most widely used diagnostic guide for both physical and mental illnesses, was first issued in 1900. The newest version, ICD-11, took effect in 2022, it’s still in the transition phase and not widely used yet. Full adoption is expected by 2027.

Many diagnoses listed in the past have disappeared. Until the late 1980s, for example, homosexuality was classified as a mental illness. Hysteria, a diagnosis typically assigned to women, was also once considered a mental disorder. This history shows that diagnoses are not purely medical; they also mirror societal views.

The idea was to allow people to be “simply ill” without moral judgment.

When personality disorders were first introduced over a century ago, they described individuals who strayed from prevailing moral norms: those who displayed excessive pride, rage, or joy, or behaved in socially unacceptable ways like boasting or stealing. With the rise of social psychiatry in the 1980s, attitudes toward diagnosis shifted. The idea was to allow people to be “simply ill” without moral judgment. Various personality disorder categories were introduced with a pragmatic goal: It was believed that only clearly defined conditions could be effectively studied and treated. But that plan didn’t work out.

“Aside from borderline personality disorder, this goal has never really been achieved,” says Babette Renneberg, professor of clinical psychology and psychotherapy at the Free University of Berlin. Renneberg has spent decades studying personality disorders and how to treat them. Even after more than 20 years, there is still little systematic research on how histrionic, schizoid, obsessive-compulsive, or paranoid personality disorders develop or how they should be treated. What causes these disorders remains largely unclear. As a result, defining them more precisely hasn’t led to much progress.

Dilution and overlap

There is little scientific support for most individual personality disorders. They are far less clearly distinguishable than the diagnostic categories suggest. Few people meet all the criteria for a single disorder, which leads to dilution: Two people with the same diagnosis, say obsessive-compulsive personality disorder, may not share a single symptom. Paranoid personality disorder can mean being hypersensitive and resentful or being so mistrustful that one believes in conspiracies. Anxious personality disorder allows for 64 different combinations of symptoms that still lead to the same diagnosis.

Many of these disorders significantly overlap.

At the same time, many of these disorders significantly overlap. Dependent, obsessive-compulsive, and avoidant disorders often go hand in hand with negative emotions like anxiety, insecurity, or depressive moods. Impulsivity is a feature not only of antisocial personality disorders, but also of borderline, paranoid, and obsessive-compulsive types. This overlap makes it difficult to clearly assign a person to just one category: many qualify for multiple at the same time.

You could say the diagnostic categories were like filing cabinets that created more confusion than clarity. They separated male and female patients into different drawers even when they belonged in the same one, and grouped together files that had nothing in common.

The impact on treatment

In practice, this meant that someone describing herself as emotionally unstable, obsessive-compulsive and dependent on others might be diagnosed very differently depending on the therapist or clinic, ranging from borderline personality disorder to obsessive-compulsive disorder. These diagnoses also shaped treatment.

More problematic still is how arbitrarily the line between “sick” and “healthy,” or “normal” and “abnormal,” has been drawn so far.

With the exception of borderline and avoidant-anxious personality disorders, there are no specific treatment plans for any personality disorder. There’s no coherent explanation of how each diagnosis arises, how it is sustained, or what might bring about lasting change. Therapists often focused on symptoms: For someone diagnosed with narcissistic personality disorder, treatment centered on their sense of entitlement or problems with criticism, without addressing the deeper causes.

More problematic still is how arbitrarily the line between “sick” and “healthy,” or “normal” and “abnormal,” has been drawn so far. There is no reliable research showing that a particular set of characteristics, in a particular number, defines the boundary of a disorder.

Outdated diagnoses

Some diagnoses seem outdated anyway. Take histrionic personality disorder, which criticizes theatrical displays of emotion: “I no longer believe it’s appropriate to pathologize this,” says psychologist Babette Renneberg. “In individualistic societies, dramatic, expressive behavior often goes unnoticed or is even welcomed.”

They have begun searching for a new model: a common core that might lie at the root of these diverse, overlapping disorders.

The same goes for dependent personality disorder, where a high need for care might now be seen as a response to a complex world rather than a sign of illness. Even obsessive-compulsive personality disorder blurs into what many consider positive traits, like perfectionism and a strong sense of order.

All of this has led patients and researchers alike to question the old categories. They have begun searching for a new model: a common core that might lie at the root of these diverse, overlapping disorders.

A new approach

There is one thing all personality disorders seem to share: People affected often struggle with an unstable sense of self. They may not be entirely sure who they are or what they want. This uncertainty makes it difficult for them to control their behavior, especially in relationships. They may withdraw for fear of rejection, act impulsively, or feel overwhelmed. These emotional ups and downs often lead to conflict and strain relationships.

The goal is to better reflect the full complexity of personality disorders and tailor treatment more closely to each person’s needs.

This central feature now shapes the new diagnostic approach in ICD-11. Instead of rigid categories, there is now a single diagnosis: “personality disorder.” It will be classified by severity (mild, moderate, or severe) based on how much the symptoms interfere with someone’s life. The goal is to better reflect the full complexity of personality disorders and tailor treatment more closely to each person’s needs. The only exception is borderline personality disorder, which will remain as a separate diagnosis because it is especially well-researched and treatable.

Therapists can also describe personality patterns to complement the diagnosis. These are based on a well-established, cross-cultural personality model known as the “Big Five.” It identifies five traits: openness, conscientiousness, agreeableness, extraversion and neuroticism, which vary from person to person.

For diagnosing disorders, a maladaptive version of this model is used: Someone with a personality disorder might not just be open to new experiences but may throw themselves into them recklessly. They might not just be conscientious but obsessively perfectionist. Not just introverted but anxious about intimacy. Not just disagreeable but harsh and cold. Not just neurotic but emotionally volatile.

Unclear thresholds

But how can you tell where the line is? How do you know when a personality trait becomes a problem or when someone just has a different way of being? When does a mild personality disorder start? Where is the difference between introverted and socially withdrawn, or between energetic and dangerously impulsive?

One key measure is subjective distress: whether someone is suffering from their behavior or repeatedly has conflict with others. But that can be tricky to gauge, as it depends a lot on personal, social and cultural factors. The boundary remains vague, and that’s one of the biggest challenges of this new approach. Clear rules for what counts as mild, moderate, or severe don’t yet exist, nor are there standard tools or benchmarks. These will need to be developed.

For therapists, this means they have to judge for themselves how strongly someone’s personality patterns are affecting their life and well-being, whether that person needs support or just has a different temperament. Without clear-cut thresholds, much hinges on the therapist’s own judgment, which brings greater responsibility.

Treatment can be more precisely tailored.

This is one of the criticisms of ICD-11. While its dimensional approach is meant to allow more nuanced evaluations of personality traits, many say it is still too complex and underdeveloped in practice. Critics argue that the lack of standardization can cause uncertainty, and that therapists need more time and training to apply it effectively.

Still, many professionals support the shift. ICD-11 promises more personalized therapies by moving away from rigid categories and instead focusing on individual traits and how they function. That way, treatment can be more precisely tailored to the difficulties someone faces.

Therapies like mentalization-based treatment (MBT) or schema therapy, originally designed for specific diagnoses like borderline personality disorder, already align well with the new model. They address issues like identity, impulse control, and relationship skills, the very dimensions now seen as central to all personality disorders in ICD-11. Research shows that schema therapy works not just for borderline but also for narcissistic and avoidant personality disorders, significantly reducing symptoms and unhealthy patterns. However, therapy tools specifically designed for the new model are still lacking, and clinical rollout is just beginning.

Other advantages

Stigma could also decline. Under the new model, personality disorders are no longer automatically considered lifelong. Studies show that with appropriate treatment, many people diagnosed with a personality disorder no longer meet the criteria after a while. One long-term study found that more than 50% of those with borderline personality disorder had improved significantly after just two years. Long-term data also suggests that change is possible for other types like avoidant-anxious or obsessive-compulsive disorders, although more gradually.

That’s why ICD-11 now specifies, for the first time, that symptoms must persist for at least two years, instead of simply being “enduring” as before. So personality disorders are no longer viewed as fixed traits, but as patterns that can shift with support.

The dimensional system could foster more understanding.

Negative stereotypes tied to certain diagnoses could also fade under the broader diagnosis. The old categories often came with harsh labels in the public eye. Narcissistic: arrogant. Schizoid: weird. Histrionic: annoying. These impressions were often shaped less by medical definitions than by cultural bias, making people seem unlikeable.

That’s exactly why experts like Renneberg are pushing for a new mindset: “If we really embrace the dimensional system, it could foster more understanding.” When we let go of rigid labels, we can ask more thoughtful questions: What exactly is it about this behavior that troubles me? What’s the underlying issue, the pattern? And what role do I play in it?

Seen this way, the new diagnostic model is also an invitation: to more nuance, more self-reflection, and a more humane view of what it means to be normal.