Pathological Narcissism and Narcissistic Personality Disorder

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Pathological Narcissism
and Narcissistic Personality
Disorder
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Aaron L. Pincus and Mark R. Lukowitsky


Department of Psychology, The Pennsylvania State University, University Park,
Pennsylvania 16802; email: [email protected], [email protected]

Annu. Rev. Clin. Psychol. 2010. 6:8.1–8.26 Key Words


The Annual Review of Clinical Psychology is online personality disorders, criterion problem, narcissistic grandiosity,
at clinpsy.annualreviews.org
narcissistic vulnerability, diagnosis
This article’s doi:
10.1146/annurev.clinpsy.121208.131215 Abstract
Copyright  c 2010 by Annual Reviews. We review the literature on pathological narcissism and narcissistic per-
All rights reserved
sonality disorder (NPD) and describe a significant criterion problem re-
1548-5943/10/0427-0001$20.00 lated to four inconsistencies in phenotypic descriptions and taxonomic
models across clinical theory, research, and practice; psychiatric diagno-
sis; and social/personality psychology. This impedes scientific synthesis,
weakens narcissism’s nomological net, and contributes to a discrepancy
between low prevalence rates of NPD and higher rates of practitioner-
diagnosed pathological narcissism, along with an enormous clinical lit-
erature on narcissistic disturbances. Criterion issues must be resolved,
including clarification of the nature of normal and pathological narcis-
sism, incorporation of the two broad phenotypic themes of narcissistic
grandiosity and narcissistic vulnerability into revised diagnostic crite-
ria and assessment instruments, elimination of references to overt and
covert narcissism that reify these modes of expression as distinct narcis-
sistic types, and determination of the appropriate structure for patho-
logical narcissism. Implications for the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders and the science of personality
disorders are presented.

8.1

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2008), and despite narcissism’s longevity as a


Contents construct in psychology and psychiatry, action
must be taken to resolve disjunctions and in-
INTRODUCTION . . . . . . . . . . . . . . . . . . 8.2
tegrate findings in future conceptualizations of
PHENOTYPIC AND
pathological narcissism, otherwise continuing
TAXONOMIC ISSUES . . . . . . . . . . . 8.2
disparate efforts will impede progress toward a
Organizing the Tower of Babel:
more sophisticated understanding of this com-
Phenotypic and Taxonomic
plex clinical construct. When this state of affairs
Inconsistencies in
is combined with potentially significant revi-
Conceptualizations
sions to the personality disorders in the upcom-
of Narcissism . . . . . . . . . . . . . . . . . . . 8.3
ing DSM-V (Clark 2007, Krueger et al. 2008),
ASSESSMENT. . . . . . . . . . . . . . . . . . . . . . . 8.11
the current status of pathological narcissism and
Narcissistic Personality Disorder . . . 8.12
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NPD are truly in flux.


Pathological Narcissism . . . . . . . . . . . . 8.12
There have been a number of valuable and
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

Narcissism and the Five-Factor


comprehensive reviews of pathological narcis-
Model of Personality . . . . . . . . . . . . 8.14
sism and NPD in recent years (Cain et al. 2008;
Limitations of Self-Reports,
Levy et al. 2007, 2009; Ronningstam 2005a,b,
Interviews, and Observer-Based
2009). Taken as a whole and with varying em-
Measures . . . . . . . . . . . . . . . . . . . . . . . 8.14
phases, these reviews document many of the is-
Informant Ratings . . . . . . . . . . . . . . . . . 8.15
sues giving rise to the difficulties integrating
RECOMMENDATIONS AND
scientific and clinical knowledge on narcissistic
FUTURE DIRECTIONS . . . . . . . . . 8.15
disturbances, and they provide excellent sum-
CONCLUSION . . . . . . . . . . . . . . . . . . . . . 8.17
maries of the contemporary clinical and empir-
ical literature. In this article, we hope to avoid
simply providing a redundant review and take a
number of steps to achieve this aim. First, our
INTRODUCTION initial sections review and delineate problems
Narcissism: ability to
regulate self-esteem The concept of narcissism can be traced to with construct definition and suggest potential
and manage needs for the Greek myth of Narcissus and its retelling ways to clarify the construct of narcissism amid
affirmation, validation,
in Homeric hymns. Narcissism has a relatively the phenotypic and taxonomic diversity found
and self-enhancement
from the social long history as a psychological construct as in the literature. Second, when we turn to an ex-
environment well, beginning with Havelock Ellis (1898) and amination of assessment, we consider the topic
NPD: narcissistic early psychoanalytic theorists (e.g., Freud 1914) with regard to the major phenotypic and taxo-
personality disorder through the development of object relations nomic issues we discuss next.
DSM-V: Diagnostic and self psychological theories (Kernberg 1967,
and Statistical Manual Kohut 1968) and later ascribed to Axis II of
of Mental Disorders, the Diagnostic and Statistical Manual of Men- PHENOTYPIC AND
Fifth Edition tal Disorders, Third Edition (DSM-III; Am. Psy- TAXONOMIC ISSUES
Criterion problem: chiatr. Assoc. 1980) as narcissistic personal- Reviews of the literature on pathological
inconsistent construct ity disorder (NPD). Since the publication of narcissism and NPD converge in concluding
definition leading to
DSM-III Axis II, both clinical interest and that the clinical phenomenology described
disparate
operationalizations, psychological research on narcissism have in- across—and even within—disciplines is quite
assessment creased. There is now a broad theoretical and diverse (Ronningstam 2005b, 2009) and that
instruments, and empirical literature on narcissism that spans the narcissism is inconsistently defined and assessed
research programs that related fields of clinical psychology, psychiatry, across clinical psychology, psychiatry, and so-
hamper development
and social/personality psychology. However, cial/personality psychology (Cain et al. 2008).
of a cohesive
knowledge base this literature is poorly calibrated across the dis- This leads to a fundamental criterion problem
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one that is particularly vexing for complex psychiatric diagnosis, and social/personality
constructs such as narcissism and many other psychology raises fundamental questions about
mental disorders (Acton 1998). Simply put, the appropriate descriptive characteristics
there is no gold standard as to the meaning of and diagnostic criteria that best exemplify
the construct and thus whether it is clinically narcissism. This is truly unfortunate because
described or empirically measured, it can be we strongly believe pathological narcissism
difficult to synthesize among and across clinical is an important clinical problem associated
observations and empirical findings. In his with significant functional impairments (Miller
general discussion of the criterion problem and et al. 2007, Stinson et al. 2008) and several
related construct validity issues in clinical psy- related areas of maladjustment, including DSM
chology, McGrath (2005) observed that “The Axis I disorders, psychopathy, interpersonal
disparity between the diagnostic nomenclature problems and relational dysfunction, substance
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and actual psychiatric phenomena is largely use and abuse, aggression and sexual aggres-
ignored, and extensive research is conducted sion, impulsivity, homicidal ideation, and
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

to understand the psychosocial and treatment parasuicidal/suicidal behaviors (Pincus et al.


implications of the existing diagnostic cate- 2009; Ronningstam 2005a,b). We identified
gories” (p. 114). We can think of no better four interpenetrating aspects of descriptive
summary of the state of affairs found in the phenomenology and taxonomy that are incon-
current clinical and empirical literature on sistently addressed in the literature on patho-
pathological narcissism and particularly NPD. logical narcissism and NPD, leading to a poorly
This disparity is also evident when comparing coordinated theoretical and empirical base and
the low prevalence rate (0.0% to 5.7%, median a patchy nomological net. These inconsisten-
<1.0%) of DSM NPD diagnosis in most cies involve diversity in conceptualizations of
epidemiological studies (Mattia & Zimmerman narcissism’s Nature (Normal, Pathological),
2001, Zimmerman et al. 2005) with the greater Phenotype (Grandiosity, Vulnerability), Ex-
frequency of narcissistic diagnosis found in pression (Overt, Covert), and Structure (Cat-
clinical practice (Doidge et al. 2002, Morey egory, Dimension, Prototype) (see Figure 1).
& Ochoa 1989, Ronningstam & Gunderson
1990, Shedler & Westen 2007, Westen 1997, Pathological and normal narcissism. Nar-
Westen & Arkowitz-Westen 1998). It is notable cissism can be conceptualized as one’s capac-
that the most recent epidemiological study ity to maintain a relatively positive self-image
of NPD (Stinson et al. 2008) found a higher through a variety of self-, affect-, and field-
lifetime prevalence rate than did many prior regulatory processes, and it underlies individ-
studies (men, 7.7%; women, 4.8%). Investi- uals’ needs for validation and affirmation as
gations of epidemiological and practitioner well as the motivation to overtly and covertly
diagnostic rates suggest that, like the diversity seek out self-enhancement experiences from
of clinical psychology itself, the prevalence of the social environment (Pincus et al. 2009).
NPD and pathological narcissism likely varies Most theorists suggest narcissism has both
according to clinical setting, type of practice, normal and pathological expressions reflect-
and theoretical orientation (Levy et al. 2007). ing adaptive and maladaptive personality orga-
nization, psychological needs, and regulatory
mechanisms, giving rise to individual differ-
Organizing the Tower of Babel: ences in managing needs for self-enhancement
Phenotypic and Taxonomic and validation (Kernberg 1998, Kohut 1977,
Inconsistencies in Conceptualizations Morf 2006, Pincus 2005, Ronningstam 2009,
of Narcissism Stone 1998). Some suggest that normal and
The diversity of phenotypic description and pathological narcissism lie on a single contin-
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Figure 1
Phenotypic and taxonomic inconsistencies in conceptualizations of narcissism.

functioning (e.g., Cooper 2005, Paulhus 1998, assesses “subclinical narcissism” (e.g., Paulhus
Ronningstam 2005a, Watson 2005), whereas & Williams 2002, Wallace & Baumeister 2002).
others suggest adaptive and pathological nar- Using both student and clinical samples, Miller
cissism may be two distinct personality dimen- and colleagues (Miller et al. 2009) reported
sions (e.g., Ansell 2006, Pincus et al. 2009). relatively convergent profiles when comparing
The vast majority of empirical research on the patterns of correlations of NPI scores and
normal narcissism has been conducted by so- NPD assessed with the Structured Clinical In-
cial/personality psychologists measuring nar- terview for DSM-IV Axis II Personality Disor-
cissistic personality traits in nonclinical (often ders (SCID-II) with facets of the NEO Person-
student) samples. This research is dominated by ality Inventory-Revised (NEO-PI-R; Costa &
the use of the Narcissistic Personality Inventory McCrae 1992) and the HEXACO-Personality
(NPI; Raskin & Hall 1979, 1981) as the main Inventory (HEXACO-PI; Lee & Ashton 2004).
self-report measure of narcissism. Although Both NPI and NPD profiles emphasized Dis-
originally developed with reference to the in- agreeableness, whereas NPI profiles reflected
troduction of NPD criteria in DSM-III, factor greater Extraversion than did NPD profiles.
analytic studies of the NPI have demonstrated Although Miller et al. (2009) concluded that
an unstable factor structure with two- (Corry the NPI assesses general personality traits con-
et al. 2008), three- (Kubarych et al. 2004), four- sistent with NPD and thus is a useful mea-
(Emmons 1987), and seven- (Raskin & Terry sure for the study of NPD, it is notable that
1988) factor solutions reported. Of these, only their patient sample scored higher than their
Raskin & Terry (1988) felt their seven factors student sample on NPD ratings, whereas the
reflected DSM NPD criteria. Unfortunately, student sample scored higher than the patient
no NPI subscales based on these factor solu- sample on the NPI. In a related study, Miller
tions exhibit acceptable levels of internal con- & Campbell (2008) compared the five-factor
NPI: Narcissistic sistency (del Rosario & White 2005), and thus model correlates of the NPI and another clin-
Personality Inventory
most recent studies employ only the NPI total ical measure of narcissism, the Personality Di-
SCID-II: Structured score or the recent shortened version (NPI-16; agnostic Questionnaire (PDQ-4; Hyler 1994),
Clinical Interview for
Ames et al. 2006). and concluded that the conceptualization of
DSM-IV Axis II
Personality Disorders Consistent with a single continuum view- narcissism diverged across clinical psychol-
V I E point, some investigators propose the NPI ogy and social/personality psychology. They
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found that although both measures were asso- by the NPI, and Pincus et al. (2009) reported
ciated with an antagonistic interpersonal style, that in a small clinical sample, the NPI cor-
the NPI assessed an emotionally resilient, ex- related positively with self-esteem, correlated
SWAP-II: Shedler-
traverted form of narcissism, whereas the PDQ- negatively with shame, and exhibited small neg- Westen Assessment
4 assessed an emotionally unstable, negative- ative relations with aspects of psychotherapy Procedure-II
affect-laden, introverted form of narcissism. presentation and utilization.
Other investigators recommend manipulating Given that the NPI has been used in only
NPI scoring procedures to distinctly assess two studies employing clinical samples and,
“healthy” and “unhealthy” forms of narcissism unlike NPD, consistently correlates positively
(e.g., Horton et al. 2006), and still others con- with measures of adjustment and negatively
clude that the NPI mainly assesses adaptive nar- with measures of maladjustment, we are not
cissism (e.g., Ansell 2006, Pincus et al. 2009, convinced that patterns of correlations with
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Watson et al. 2005–2006). general models of personality traits that con-


This ambiguity reflects the diverse empiri- verge with NPD ratings are sufficient evidence
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

cal associations found with the NPI. The re- to conclude that the NPI assesses pathologi-
sults of both experimental and correlational cal narcissism. Although this debate continues,
research describe individuals with high NPI we assert that the NPI does not assess sub-
scores as being reactive to unmet expectations, clinical narcissism reflecting a continuum of
resistant to feedback disconfirming of positive functioning, but rather predominantly assesses
self-views, manipulative, self-enhancing, prone nondistressed adaptive expressions of the con-
to aggression, and exhibiting a dominant inter- struct. However, we believe that the corpus of
personal style (Bushman & Baumeister 1998, social/personality psychology research utilizing
Morf 2006, Morf & Rhodewalt 2001, Paulhus the NPI can make important contributions to
& Williams 2002). Paulhus (1998) reported that the study of narcissism by conceptualizing nor-
the grandiose self-enhancement style associated mal narcissism and pathological narcissism as
with high NPI scores leads to hostility and in- distinct individual differences.
terpersonal rejection over time. However, re- Other research programs also distinguish
search also demonstrates that the NPI assesses between adaptive/normal and pathological nar-
adaptive characteristics. For example, high NPI cissism. Wink identified three narcissistic pro-
scores are negatively associated with trait neu- totype scales for the California Q-set (Block
roticism and depression and positively asso- 1978), labeled Willfulness, Hypersensitivity,
ciated with achievement motivation and self- and Autonomy (Wink 1992, 1996; Wink et al.
esteem (Brown et al. 2009, Lukowitsky et al. 2005). Autonomy correlated with self-ratings
2007, Rhodewalt & Morf 1995, Watson et al. and partner-ratings of creativity, empathy,
1992). Many investigators have attempted to achievement orientation, and individualism.
empirically tease apart the consistently positive These prototypes were validated in a series of
associations found between the NPI and self- longitudinal studies predicting a variety of life
esteem as well as other measures of well-being outcomes that showed the Autonomous pro-
(e.g., Brown & Zeigler-Hill 2004, Campbell totype was generally associated with positive
et al. 2007, Sedikides et al. 2004, Zeigler-Hill trajectories, leading Wink (1992) to interpret
2006). Several researchers have pointed out that it as an indicator of healthy narcissism. Simi-
the content of the NPI total score may reflect a larly, based on Q-factor analysis of NPD pa-
confusing mix of adaptive and maladaptive con- tient ratings on the Shedler-Westen Assess-
tent (e.g., Emmons 1984, 1987; Watson et al. ment Procedure (SWAP-II; Shedler & Westen
1999–2000), with the latter being limited to the 2004, 2007), three NPD subtypes were identi-
traits of entitlement and exploitativeness. How- fied: Grandiose/Malignant, Fragile, and High-
ever, Brown et al. (2009) recently demonstrated Functioning/Exhibitionistic (Russ et al. 2008).
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exaggerated sense of self-importance but were self-reported responses to either DSM crite-
also outgoing, articulate, and energetic. They ria or omnibus inventories that include per-
tended to “show good adaptive functioning and sonality disorder scales such as the MMPI-2
Narcissistic
grandiosity: use their narcissism as a motivation to succeed” and MCMI-III (Hilsenroth et al. 1996).
dysfunction (Russ et al. 2008, p. 1479). Diagnosis of NPD is associated with functional
characterized by an Normal expressions of narcissism may con- impairments and distress (Miller et al. 2007,
overvalued, entitled tribute to self-esteem and well-being by in- Stinson et al. 2008), substantial psychiatric co-
self-image;
creasing an individual’s sense of personal agency morbidity (e.g., Clemence et al. 2009), and in-
exploitative,
exhibitionistic (Oldham & Morris 1995). For example, nor- creased risk for suicide (e.g., Heisel et al. 2007,
behaviors; absorption mal narcissism supports asserting interpersonal Ronningstam et al. 2008).
in idealized fantasies; dominance (Brown & Zeigler-Hill 2004), fu- We conclude that there is significant evi-
and other maladaptive eling approach and achievement motives such dence to support the view that the nature of nar-
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self-enhancement
as competitive and mastery strivings while low- cissism is reflected in both normal adaptation
strategies
ering avoidance motivation (Foster & Trimm and pathological personality functioning. It re-
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2008, Lukowitsky et al. 2007, Wallace et al. mains unclear whether this distinction is best
2009). Concurrently, normal narcissism is as- reflected in a bipolar dimension ranging from
sociated with a tendency toward endorsing normal to pathological narcissism or as two dis-
positive illusions about the self and mini- tinct dimensions or types of narcissism. One
mizing information inconsistent with a posi- limitation of the single-dimension approach is
tive self-image (Farwell & Wohlwend-Lloyd the potential confounding of normal narcis-
1998, Morf & Rhodewalt 2001). Such individ- sism with the absence of pathological narcis-
uals tend to be ambitious, satisfied, and rela- sism (Hatcher & Rogers 2009, Peterson 2006).
tively successful (Campbell 2001, Kohut 1977, Although this foreshadows taxonomic issues re-
Ronningstam 2005a, Russ et al. 2008, Stone garding the optimal structure of narcissism that
1998, Wink 1992, Wink et al. 2005), although we address below, we first discuss issues of phe-
this may be at the cost of having disagreeable in- notypic scope and styles of expression that cre-
terpersonal relations (Miller & Campbell 2008, ate significant inconsistency and confusion in
Miller et al. 2009). the literature.
All individuals have normal narcissistic
needs and motives (Kohut 1977, Stone 1998); Narcissistic grandiosity and narcissistic vul-
however, pathologically narcissistic individu- nerability. To the layperson, the construct of
als appear particularly troubled when faced narcissism is most often associated with arro-
with disappointments and threats to their pos- gant, conceited, and domineering attitudes and
itive self-image. Since no one is perfect and behaviors (Buss & Chiodo 1991), which may
the world is constantly providing obstacles be captured by the term narcissistic grandiosity.
and challenges to desired outcomes, patholog- Grandiosity is indeed a core component of nar-
ical narcissism involves significant regulatory cissistic personality, and its clinical description
deficits and maladaptive strategies to cope with includes intrapsychic processes and behavioral
disappointments and threats to a positive self expressions. Intrapsychic processes include re-
image (Horowitz 2009; Kernberg 1998, 2009; pressing negative aspects of self- and other-
Ornstein 2009; Ronningstam 2005b). In clin- representations and distorting disconfirming
ical and psychiatric research, such pathologi- external information, leading to entitled atti-
cal expressions of narcissism are typically op- tudes and an inflated self-image without req-
erationalized (dimensionally or categorically) uisite accomplishments and skills, as well as
as reflecting NPD as found in the DSM. In engaging in regulatory fantasies of unlimited
such studies, pathological narcissism is typ- power, superiority, perfection, and adulation.
ically assessed via semistructured diagnostic Narcissistic grandiosity is often expressed be-
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acts, lack of empathy, intense envy, aggression, interpersonal relationships. Grandiose themes
and exhibitionism. This may also be covertly are emphasized in descriptions of the arrogant
enacted by providing instrumental and emo- narcissist and the psychopathic narcissist. The
Narcissistic
tional support to others but concurrently har- former copes with self-esteem dysregulation by vulnerability:
boring contempt for the person being helped creating an exaggerated sense of superiority and dysfunction
and secretly experiencing the situation as re- uniqueness as well as by engaging in grandiose characterized by a
flecting one’s own specialness, goodness, or su- fantasies. These individuals exhibit entitlement, depleted, enfeebled
self-image; angry,
perior capabilities (e.g., Nurse 1998, Pincus exploitativeness, and a lack of empathy, and ex-
shameful, and
et al. 2009). perience intense envy and aggression as a result depressed affects;
In the past 40 years, the expanding clinical of their affect dysregulation. The psychopathic self-criticality and
literature on narcissism and narcissistic person- narcissist copes with self-esteem dysregulation suicidality;
ality pathology has led to a marked prolifera- by engaging in antisocial behaviors to protect or interpersonal
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hypersensitivity and
tion of labels implying variations in the pheno- enhance their inflated self-image. Such individ-
social withdrawal
typic expression of narcissism. Cain et al. (2008) uals will commit violent criminal acts in order
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

PDM: Psychodynamic
identified more than 50 distinct labels describ- to gain admiration from others, display extreme
Diagnostic Manual
ing variability in the expression of pathological rage reactions to criticism, and are interperson-
narcissism and asserted, “While each individual ally sadistic without experiencing remorse or
conceptualization has unique clinical value, nei- empathy. Consistent with Akhtar’s (2003) and
ther future classification systems (e.g., DSM- Dickinson & Pincus’s (2003) description of nar-
V), nor intervention models, are likely to sustain cissistic vulnerability, Ronningstam’s shy nar-
such a level of diversity in diagnostic discrimi- cissists deal with self-esteem dysregulation by
nation nor is it clear that such continued pars- engaging in grandiose fantasy while also feel-
ing would facilitate an integrative understand- ing intense shame regarding their needs and
ing of pathological narcissism” (p. 640). They ambition. The dominant affect problem for shy
concluded that two broad themes of narcissistic narcissists is shame rather than envy or aggres-
dysfunction, labeled narcissistic grandiosity and sion, and they avoid interpersonal relationships
narcissistic vulnerability, could be synthesized because of hypersensitivity to rejection and
across the literature with varying degrees of criticism.
emphasis (see Table 1). Clinical theorists have The Psychodynamic Diagnostic Manual
employed themes of grandiosity and vulnera- (PDM; PDM Task Force 2006) subdivides
bility to describe the core aspects of narcissis- narcissistic personality disturbance into an
tic dysfunction through defects in self-structure Arrogant/Entitled subtype and a Depressed/
(Kernberg 1998, Kohut 1977), difficulties in the Depleted subtype. In addition to the High-
therapeutic relationship (Gabbard 2009, Kern- Functioning/Exhibitionistic subtype identified
berg 2007), and maladaptive defensive strate- by their Q-factor analyses of NPD patients’
gies used in response to stressors, such as shame SWAP-II profiles, Russ et al. (2008) described
(e.g., Broucek 1982), trauma (e.g., Hunt 1995, two pathological subtypes convergent with
Simon 2002), unfulfilled needs (e.g., Bursten the PDM. The Grandiose/Malignant subtype
1973), dependency (e.g., Cooper & Maxwell is characterized by seething anger, manip-
1995), or abandonment depression (Masterson ulativeness, pursuit of interpersonal power
1993). and control, lack of remorse, exaggerated
In recent years, recognition of both self-importance, and feelings of privilege.
grandiose and vulnerable themes of narcissis- These individuals tend to be externalizing
tic dysfunction has increasingly become the and have little insight into their behavior. In
norm. Ronningstam (2005a,b) identified sub- contrast, the Fragile subtype individuals are
types of narcissistic personality based on sim- unable to consistently maintain a grandiose
ilarities and differences in self-esteem dysreg- sense of self such that at times when their
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Table 1 Phenotypic labels for pathological narcissism reflecting grandiosity and vulnerability
Source Grandiose themes Vulnerable themes
Kohut (1971) Horizontal split Vertical split
Bursten (1973) Manipulative Craving
Phallic
Paranoid
Kohut & Wolf (1978) Mirror-hungry Ideal-hungry
Alter-ego Contact-shunning
Am. Psychiatr. Assoc. (1980) DSM-III NPD
Akhtar & Thomson (1982), Cooper (1981) Overt Covert
Broucek (1982) Egotistical Dissociative
Kernberg (1984) Pathological
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Malignant
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Rosenfeld (1987) Thick-skinned Thin-skinned


Am. Psychiatr. Assoc. (1987) DSM-III-R NPD
Cooper (1988, 2005) Narcissistic-masochistic
Gabbard (1989, 1998, 2009) Oblivious Hypervigilant
Gersten (1991) Overtly grandiose Overtly vulnerable
Wink (1992) Willful Hypersensitive
Masterson (1993) Exhibitionistic Closet
Fiscalini (1993) Uncivilized spoiled child Infantilized spoiled child
Special child Shamed child
Am. Psychiatr. Assoc. (1994) DSM-IV NPD
Cooper & Maxwell (1995) Empowered Disempowered
Manipulative
Hunt (1995) Classical Diffident
Millon (1996) Unprincipled Compensatory
Amorous
Elitist
Fanatic
Simon (2002) TANS
Akhtar (2003) Shy
Dickinson & Pincus (2003) Grandiose Vulnerable
Ronningstam (2005b) Arrogant Shy
Psychopathic
PDM Task Force (2006) Arrogant/entitled Depressed/depleted
Russ et al. (2008) Grandiose/malignant Fragile
Pincus et al. (2009) Narcissistic grandiosity Narcissistic vulnerability

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition; DSM-III-R, Diagnostic and Statistical Manual of
Mental Disorders-Third Edition, Revised; NPD, narcissistic personality disorder; PDM, Psychodynamic Diagnostic Manual;
TANS, trauma-associated narcissistic symptoms.

anxiety, depression, and feelings of inade- co-occur with vulnerable self-states and affec-
quacy. Many contemporary clinical experts tive dysregulation. Ronningstam (2009) noted,
on narcissistic personality disorder now rec- “the narcissistic individual may fluctuate be-
V I E ognize that grandiose self-states oscillate or tween assertive grandiosity and vulnerability”
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(p. 113). Similarly, Kernberg (2009) indicated vulnerable (Hypersensitive) narcissistic proto-
that narcissistic personalities endure “bouts of types using an entirely different methodolog-
insecurity disrupting their sense of grandiosity ical approach (Q-sorts), and these also exhib-
or specialness” (p. 106). Horowitz (2009) ited a distinct pattern of self- and partner-rated
suggested that as narcissistic pathology neg- correlates. Unlike Wink’s normal prototype
atively impacts relationships, creativity, and (Autonomous) discussed above, the Hypersen-
occupational adjustment, grandiosity cannot be sitive prototype was associated with negative
maintained, and “he or she is more and more life trajectories, and the Willful Prototype was
vulnerable to shame, panic, helplessness, or generally associated with flat trajectories, lead-
depression as life progresses without support ing to the suggestion that the Hypersensitive
from admiring others” (p. 126). prototype is the most pathological form of nar-
The clinical themes of grandiosity and cissism (Wink 1992, Wink et al. 2005).
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vulnerability also converge with research on In contrast to prevailing clinical theory


narcissistic traits in social/personality psy- and psychological research, revisions of DSM
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

chology. Structural evaluations of self-report NPD criteria have become increasingly nar-
measures of narcissism that included mea- row and focused exclusively on grandiosity
sures beyond the NPI consistently found ev- (Cain et al. 2008). The current DSM-IV-TR
idence for two molar dimensions (Rathvon criteria for NPD include a grandiose sense of
& Holmstrom 1996; Wink 1991, 1996). self-importance; a preoccupation with fantasies
Wink (1991) submitted six MMPI-derived of unlimited power, success, brilliance, beauty,
narcissism scales to a principal components or ideal love; a belief that he/she is “special”
analysis and found two orthogonal compo- or unique and can only be understood by,
nents labeled Vulnerability-Sensitivity (V-S) and should associate with, other special or
and Grandiosity-Exhibitionism (GE). V-S and high-status people or institutions; a need for
G-E exhibited distinct patterns of self- and excessive admiration; a sense of entitlement; in-
informant-rated correlates. Wink & Donahue terpersonal exploitativeness, a lack of empathy;
(1997) found boredom proneness to be re- often envious of others or believes that others
lated to both forms of narcissism, but in dif- are envious of him/her; and arrogant, haughty
ferent ways. G-E was related to restlessness behaviors or attitudes (Am. Psychiatr. Assoc.
and feelings of impatience in response to exter- 2000). A confirmatory factor analysis of these
nal constraints on behavior, whereas V-S was NPD criteria supported a one-factor solution
related to difficulties in keeping oneself inter- (Miller et al. 2008b). The changes to NPD cri-
ested and entertained (lack of internal stimula- teria from the DSM-III eliminated many of the
tion), feelings of meaninglessness, and the per- characteristics underlying vulnerable themes
ception that time is passing by slowly. Rathvon (e.g., shameful reactivity or humiliation in
& Holmstrom (1996) replicated Wink’s work response to narcissistic injury, alternating states
by submitting the NPI and five MMPI- or of idealization and devaluation). These are now
MMPI-2-based narcissism measures to a prin- described in the “Associated Features and Dis-
cipal components analysis and extracting two orders” section, where clinicians are also cau-
orthogonal components, labeled Depletion and tioned that patients may not outwardly exhibit
Grandiosity. Grandiosity was positively related such vulnerable characteristics (APA 2000).
to exhibitionism and negatively related to de- The lack of sufficient vulnerable DSM-IV
pression, anxiety, bodily concerns, and social NPD criteria is now a common criticism
discomfort. Depletion was positively related in the recent literature (Cain et al. 2008,
with all MMPI-2 clinical scales and supplemen- Gabbard 2009, Levy et al. 2007, Pincus et al.
tal scales assessing maladjustment. 2009, Ronningstam 2009). This narrow focus
It is also notable that Wink (1992) on grandiosity in DSM NPD likely contributes
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to reports of the diagnosis in clinical practice Overt narcissism and covert narcissism. A
noted above as well as low temporal stability second distinction found in the phenotypic de-
(e.g., Ball et al. 2001, Lenzenweger et al. 2004, scription of pathological narcissism refers to
Ronningstam et al. 1995). In a recent study its overt and covert expressions (Akhtar &
of pathological narcissism and psychotherapy Thomson 1982, Cooper 1981). This distinc-
(Pincus et al. 2009), grandiose characteris- tion was further promoted by Wink (1992),
tics most often reduced treatment utilization, who equated his Willful prototype with overt
whereas vulnerable characteristics most often narcissism and his Hypersensitive prototype
promoted treatment utilization. Thus, thera- with covert narcissism. The distinction con-
pists and diagnosticians may be more likely to tinued when Hendin & Cheek (1997) also
see narcissistic patients when they are in a vul- equated their Hypersensitive Narcissism Scale
nerable self-state. Relying solely on DSM-IV with covert narcissism. Although narcissistic
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NPD diagnostic criteria may impede clinical grandiosity and narcissistic vulnerability are
recognition of pathological narcissism. This be- far more prominent in clinical theory and re-
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

comes a significant issue when combined with search, distinguishing covert and overt narcis-
results linking pathological narcissism with sism is more common in the social/personality
homicidal ideation, parasuicidal behavior, and literature (e.g., Besser & Priel 2009, Otway &
suicide attempts. The current DSM NPD di- Vignoles 2006). We believe that this distinc-
agnosis is thus not sufficient for its original pur- tion is inaccurate, and any perpetuation of overt
pose, i.e., to facilitate the accurate diagnosis of and covert narcissism as distinct types or phe-
patients with pathological forms of narcissism. notypes simply adds to the criterion problem
The identification of two broad themes of plaguing pathological narcissism.
grandiosity and vulnerability in pathological Our view is that this distinction is simply
narcissism has implications for clinical theory, about different modes of the expression of
social/personality psychology, and psychiatric narcissistic grandiosity and narcissistic vulner-
diagnosis. We recommend that clinical theory ability. DSM NPD criteria, items on various
and psychotherapy literature end the pro- self-reports, interviews, and rating instruments
liferation of labels for narcissistic pathology assessing pathological narcissism, and most
and begin to generate a cumulative and more certainly clinical conceptualizations of all
integrated literature on conceptualization and forms of personality pathology include a mix of
treatment of pathological narcissism organized overt elements (behaviors, expressed attitudes
around grandiosity and vulnerability. To and emotions) and covert experiences (cog-
supplement social/personality psychological nitions, private feelings, motives, needs) (e.g.,
research on grandiose narcissistic traits, we sug- McGlashan et al. 2005). Our clinical experience
gest that recently developed measures assessing with narcissistic patients indicates they virtually
vulnerable narcissistic traits (e.g., Bachar et al. always exhibit both covert and overt grandios-
2005, Hendin & Cheek 1997, Pincus et al. 2009, ity and covert and overt vulnerability. Prior
Wink 1992) can complement the NPI, and we assertions linking vulnerable hypersensitivity
recommend that they be regularly included in with covert narcissism are clinically inaccurate.
research focusing on narcissistic personality In Figure 2, we present a model to clarify
even in nonclinical contexts and particularly in the overt and covert expressions of narcissistic
research investigating negative consequences grandiosity and narcissistic vulnerability. The
of trait narcissism. Finally, we recommend distinction between overt and covert expres-
that revisions of personality disorder criteria sions of narcissism is secondary to phenotypic
in DSM-V reflect sufficient content to permit variation in grandiosity and vulnerability, and
diagnosis of NPD when either narcissistic there is no empirical evidence that distinct
grandiosity or narcissistic vulnerability is pre- overt and covert types of narcissism exist. What
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Figure 2
The hierarchical organization of pathological narcissism.

relative levels of grandiosity and vulnerability Further taxometric analyses would be welcome,
and the relative prominence of their overt given that current research is limited to the NPI
and covert expressions of the entire range and DSM NPD. What is clear is that the field
of pathological narcissism. We believe that is now moving beyond debates over categories
Wink (1992) and Hendin & Cheek (1997) and dimensions as integrative models are evolv-
were correct in describing their measures as ing (De Clercq et al. 2009, Krueger et al. 2008,
assessing hypersensitivity (i.e., vulnerability). Livesley 2007, Paris 2007). Given increasing
The subsequent linking of narcissistic hy- support for dimensional models of personality
persensitivity with covert narcissism was a pathology (Clark 2007, Widiger & Trull 2007)
retrofitting of constructs that contributed to and evidence that the current DSM category of
phenotypic and taxonomic confusion. NPD is insufficient in scope, we support con-
ceptualizing pathological narcissism from a di-
mensional perspective that may be further in-
Categories, dimensions, and prototypes.
corporated into evolving integrative models.
The structure of pathological narcissism, like
that of all personality disorders, has been repre- Implications. The heterogeneity of pheno-
sented as a diagnostic category, as a set of proto- typic and taxonomic description of narcissism
types, and as a hierarchically organized set of di- found in the literature clearly impedes the ef-
mensions. Analyses of the strengths and weak- fective synthesis of the empirical and clinical
nesses of these approaches for classifying per- knowledge base. However, with such inconsis-
sonality pathology are widespread and beyond tencies kept in mind, the literature on assess-
the scope of the current review (e.g., Huprich ment of narcissism (and other domains not cov-
& Bornstein 2007, Trull & Durrett 2005, Widi- ered in this review, e.g., comorbidity, etiology,
ger & Mullins-Sweat 2005). Only two taxomet- neurobiology, treatment) can be more precisely
ric analyses of narcissism have been reported in and effectively evaluated. This is demonstrated
the literature. Taxometric evaluation of the NPI in the following sections.
in student samples indicated narcissistic traits
were best represented dimensionally, and no ev-
idence of taxonicity was found (Foster & Camp- ASSESSMENT
bell 2007). In contrast, taxometric analyses of Although reliable and valid assessment of
the DSM-IV criteria in a large patient sam- all personality disorders has historically been
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inconsistencies in conceptualizations of narcis- Multiphasic Personality Inventory (MMPI-


sism we have noted (i.e., the criterion prob- 2) Personality Disorder Scales (Hicklin &
lem) result in limited psychometric conver- Widiger 2000, Somwaru & Ben-Porath 1995),
gence across the large number of measures the Schedule for Nonadaptive and Adaptive
and instruments to assess narcissism (Chatham Personality (SNAP) Personality Disorder
et al. 1993, Hilsenroth et al. 1996, Samuel & Scales (Clark 1993), the OMNI Personality
Widiger 2008). Efforts to integrate clinical sci- Inventory (OMNI; Loranger 2001), and
ence and practice and to develop a cumulative the Personality Diagnostic Questionnaire-4
base of knowledge are difficult when the nature, (PDQ-4; Hyler 1994).
phenotypic range, modes of expression, and The PDQ-4 is purported to be the self-
structure of narcissistic constructs vary widely report measure most directly related to DSM-
across instruments. IV criteria (Widiger & Coker 2002). Despite
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this, Miller & Campbell (2008) found that the


PDQ-4 NPD scale assesses an emotionally un-
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

Narcissistic Personality Disorder stable, negative-affect-laden, and introverted


A number of semistructured interviews, form of narcissism. In another study, Miller and
observer ratings, and self-reports for DSM colleagues (Miller et al. 2008a) also found that
personality disorders assess NPD. Although specific PDQ-4 items did not converge on the
substantial differences between the instruments DSM NPD criteria they were supposed to as-
exist, and validity data for many instruments’ sess when compared to consensus ratings de-
specific diagnoses are sparse, all are based on termined by the Longitudinal, Expert, All Data
the DSM; thus, in one way or another, all procedure (LEAD; Pilkonis et al. 1991). Al-
NPD measures assess aspects of narcissistic though intended to assess DSM NPD, the cor-
grandiosity. However, as noted above, relying responding PDQ-4 scale seems to assess some
solely on the narrow DSM NPD conception of the more vulnerable aspects of pathological
and diagnostic criteria may impede clinical narcissism. However, Miller et al. (2008a) cau-
recognition of pathological narcissism. tioned against using the scale as a stand-alone
Diagnostic interviews for NPD include the indicator of narcissistic vulnerability.
Structured Interview for DSM-IV Personality
(SIDP-IV; Pfohl et al. 1997), the SCID-II
(First et al. 1995), the International Person- Pathological Narcissism
ality Disorder Examination (IPDE; Loranger Several omnibus self-report measures of patho-
1999), the Personality Disorder Interview- logical personality traits contain scales that
IV (PDI-IV; Widiger et al. 1995), and the assess narcissism. These include the Dimen-
Diagnostic Interview for Personality Disorders sional Assessment of Personality Pathology-
(DIPD; Zanarini et al. 1987). Observer-based Basic Questionnaire (DAPP; Livesley 2006)
measures that allow for the assessment of NPD and the SNAP (Simms & Clark 2006). The
include the Personality Assessment Form (PAF; Personality Assessment Inventory (PAI; Morey
Shea et al. 1990) and the Shedler-Westen As- 1991) does not include specific narcissism
sessment Procedure-II (SWAP-II; Westen & scales, although diagnostic algorithms for as-
Shedler 2007, Westen et al. 2006). Finally, self- sessing narcissism have been proposed (Morey
report inventories containing scales to assess 1996). As with many of the individual mea-
NPD include the Millon Clinical Multiaxial sures of NPD derived from omnibus invento-
Inventory (MCMI-III; Millon et al. 1997), the ries, there is little published validity data on in-
Wisconsin Personality Disorders Inventory dividual SNAP and DAPP narcissism scales or
(WISPI-IV; Klein et al. 1993), the Assessment the PAI narcissism algorithm, and the extent of
of DSM-IV Personality Disorders (ADP-IV; their grandiose and vulnerable content is not
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A number of unidimensional self-report Scale (NVS) to assess narcissistic vulnerability


measures have also been created specifically to to trauma. The NVS assesses three narcissistic
assess either narcissistic grandiosity or narcis- traits: Grandiosity, Exploitativeness, and Poor
HSNS:
sistic vulnerability. Campbell et al. (2004) de- Self-Esteem Regulation. The first two scales Hypersensitive
veloped the Psychological Entitlement Scale correlated positively with the NPI, whereas the Narcissism Scale
(PES) to improve upon its NPI counterpart and third scale was unrelated to the NPI and may PNI: Pathological
to assess the negative consequences associated tap aspects of narcissistic vulnerability. Narcissism Inventory
with this core narcissistic trait. However, recent Most recently, Pincus and colleagues de- DIN: Diagnostic
analyses suggested that the PES does not fully veloped the Pathological Narcissism Inventory Interview for
converge with the Entitlement subscale of the (PNI; Pincus et al. 2009), a 52-item multidi- Narcissism
NPI (Pryor et al. 2008) and possibly assesses mensional self-report measure of pathological
a related but distinct personality trait (Brown narcissism that assesses seven characteristics
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et al. 2009). In order to capture aspects of nar- spanning grandiose and vulnerable affect
cissistic vulnerability, Hendin & Cheek (1997) and self states as described in the clinical,
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

developed the Hypersensitive Narcissism Scale psychiatric, and social/personality psychology


(HSNS). The HSNS is uncorrelated with the literature (Cain et al. 2008). Confirmatory
NPI and moderately correlated with MMPI factor analyses (Wright et al. 2008) provided
measures that load on Wink’s (1991) V-S com- additional evidence for a higher-order two-
ponent. Validity evidence for the HSNS is accu- factor structure that captures the themes
mulating, including predicted associations with of narcissistic grandiosity (Exploitativeness,
dating violence (Ryan et al. 2008), sensitivity Grandiose Fantasy, Self-Sacrificing Self-
to criticism (Atlas & Them 2008), insecure at- Enhancement) and narcissistic vulnerability
tachment (Smolewska & Dion 2005), and rec- (Contingent Self-Esteem, Entitlement Rage,
ollected parenting (Otway & Vignoles 2006). Devaluing, Hiding the Self ). The measure
Although frequently associated with covert nar- was validated in a normal sample and in a
cissism in the empirical literature, we assert that small clinical sample where the scales exhib-
studies examining the HSNS relative to overt ited significant associations with parasuicidal
narcissism (typically the NPI) can be better un- behavior, suicide attempts, and homicidal
derstood as contrasting narcissistic vulnerabil- ideation. The PNI was also shown to be asso-
ity with narcissistic grandiosity. ciated with a range of interpersonal problems
Multidimensional measures of pathologi- in theoretically meaningful ways, correlated
cal narcissism typically contain scales assess- negatively with self-esteem and empathy, and
ing both narcissistic grandiosity and narcissistic correlated positively with shame, interpersonal
vulnerability. An early multidimensional mea- distress, aggression, and borderline personality
sure was the Superiority and Goal Instability organization. High scores on the PNI also
Scales (SGIS; Robbins 1989, Robbins & Patton predicted self-reported stalking behaviors in
1985) based on Kohut’s theory of narcissism. a large college student sample (Marino et al.
The Superiority Scale was designed to measure 2009, Ménard & Pincus 2009). The PNI thus
the grandiose and exhibitionistic aspects of the appears to be appropriate for both clinical and
self, whereas the Goal Instability Scale was de- nonclinical populations and is currently the
signed to measure identity issues about the self only multifaceted measure assessing clinically
and may reflect vulnerable aspects of patholog- identified characteristics spanning the full
ical narcissism. The Goal Instability Scale has phenotypic range of pathological narcissism.
been used extensively in vocational and career Two other instruments assessing pathologi-
counseling (e.g., Casillas et al. 2006), but the cal narcissism should be mentioned. First, the
SGIS has not been used frequently in clinical re- Diagnostic Interview for Narcissism (DIN;
search on pathological narcissism. Bachar et al. Gunderson et al. 1990) represents the lone
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assess pathological narcissism based on the symptom counts and the PSY-5 scales sug-
authors’ phenomenological studies (e.g., gested that NPD was strongly and positively
Ronningstam & Gunderson 1988, 1990, 1991). correlated with aggressiveness and psychoti-
This interview has recently been extended to a cism, moderately and positively correlated with
parent report for assessment of narcissism in negative emotionality/neuroticism and discon-
youth (Bardenstein 2009, Guilé et al. 2004). straint, and not significantly correlated with in-
The DIN is associated with DSM NPD, troversion/low positive emotionality.
but examination of the interview questions Samuel & Widiger (2008) recently used
suggested to us that it likely assesses aspects the NEO-PI-R to compare five different mea-
of narcissistic grandiosity and narcissistic sures of narcissism: the MMPI-2, MCMI-III,
vulnerability. Empirical examination of the PDQ-4, NPI, and SNAP. Consistent with pre-
phenotypic scope of the DIN would be a vious reports (e.g., Hilsenroth et al. 1996), there
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useful start as there is currently no validated was a substantial degree of variability in conver-
interview to assess narcissistic vulnerability. gence across the measures of narcissism. Re-
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

Finally, Wink’s (1992) measure of narcissism sults also suggested an inconsistent pattern of
based on the California Q-set allows for the correlations between the narcissism measures
assessment of both grandiose (Willful) and and the domains of the FFM. For example, the
vulnerable (Hypersensitive) prototypes. MCMI-III and MMPI-2 narcissism scales con-
sisted of low neuroticism, high extraversion,
and marginal antagonism, whereas the PDQ-
Narcissism and the Five-Factor Model 4 and the SNAP consisted of little to no ex-
of Personality traversion or neuroticism but high antagonism.
Theorists have also suggested that the Five- The NPI fell between the other measures and
Factor Model (FFM) of personality can be used consisted of high extraversion and antagonism.
to both conceptualize and assess NPD (Corbitt The authors concluded that all five measures
2002). With regard to narcissism, the most con- of narcissism share a conceptualization that in-
sistent findings are that there is a strong positive cludes narcissistic grandiosity but that none
correlation between NPD and extraversion, of them seem to reflect aspects of narcissistic
a strong negative correlation between NPD vulnerability.
and agreeableness, and a modest negative cor-
relation between NPD and conscientiousness
(Saulsman & Page 2004). As would be expected Limitations of Self-Reports,
given phenotypic inconsistencies, the findings Interviews, and Observer-Based
regarding the correlation between NPD and Measures
neuroticism are inconsistent and depend upon Although interview, self-report, and observer-
the measure of narcissism being employed (e.g., based measures all represent important
Trull 1992). The Personality Psychopathology methods for assessing pathological narcissism,
Five (PSY-5) (Harkness & McNulty 1994) was they also have some important limitations. For
developed based on scales from the MMPI-2 in example, both observer-based assessments and
order to more fully capture personality pathol- interviews require that that the assessor make a
ogy based on a five-factor structural model. judgment about personality traits that have typ-
In a recent study comparing the PSY-5 and ically been observed for only a short period of
the NEO-PI-R, Bagby et al. (2008) found that time. Interview-based measures also suffer from
the combined PSY-5 domains were better than some of the same limitations that affect self-
the combined NEO-PI-R domains at predict- reports in that they may be subject to biased,
ing narcissistic personality disorder symptom distorted, or otherwise misleading information,
counts when using the SCID-II-PQ as a cri- particularly if assessing socially undesirable
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tions based on these methods of assessment between self- and other reports on the FFM at
alone are unlikely to provide a complete under- both the facet and domain level and that, in gen-
standing of personality pathology (Oltmanns eral, informants’ ratings indicated significantly
& Turkheimer 2006, 2009). Hilsenroth et al. higher levels of NPD than did the patients’ rat-
(1996) argued for a multimethod assessment ings. A series of studies on interpersonal per-
that includes self-reports, semistructured ception of personality disorders (Clifton et al.
interviews, and projective measures. Although 2004, 2005, 2007; Oltmanns et al. 2004, 1998;
projective tests including the Rorschach may be Thomas et al. 2003) found little cross-source
quite capable of detecting narcissistic defenses convergence for narcissism but significant con-
in less overt presentations of the disorder, sensus among peers. In addition, studies found
research using the Rorschach has largely been that narcissism, more than any other PD, re-
limited to its ability to predict DSM NPD flected a greater distortion in interpersonal
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criteria and its relationship to MMPI-2 NPD perception that was characterized by individ-
scales (Handler & Hilsenroth 2006). uals putting a positive and self-enhancing spin
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

on their personality while being described by


peers as domineering, vindictive, and intrusive.
Informant Ratings Consistent with these studies, Lukowitsky &
A number of researchers have also argued for Pincus (2009) found low self-other agreement
the importance of obtaining informant ratings for pathological narcissism assessed with the
when assessing adult psychopathology (e.g., PNI. However, individuals identified as high
Achenbach et al. 2005, Klonsky et al. 2002, in pathological narcissism agreed with others
Westen & Shedler 1999). Investigations that about their level of interpersonal problems,
have included self- and other ratings have suggesting that although these individuals may
demonstrated that both sources provide rela- have a narcissistic blind spot, they do have some
tively independent and incremental informa- awareness of their interpersonal distress.
tion that can be used to make more informed
diagnoses and predictions (e.g., Fiedler et al.
2004, Klein 2003, Miller et al. 2005, Olt- RECOMMENDATIONS AND
manns et al. 2002). Given the diminished level FUTURE DIRECTIONS
of self-reflection attributed to individuals with Clinical conceptualizations of pathological nar-
personality disorders and NPD in particular cissism and NPD are at a crossroads. There is
(Dimaggio et al. 2007; Oltmanns et al. 2005), a significant criterion problem that must be re-
the inclusion of multiple sources of assessment solved in order to synthesize current research
is particularly important. Indeed, a review of and clinical practice and develop a more cohe-
self-other concordance for personality disor- sive nomological net. In our view, the current
ders suggested that, at best, there is only a mod- situation is similar to issues in the relationship
est relationship between the way individuals between psychopathy and antisocial personal-
with personality disorders view themselves and ity disorder (Hare & Neuman 2008). Like psy-
the way they are viewed by others, with NPD chopathy, pathological narcissism is a broader
being particularly prone to self-other discrep- construct that is strongly related to its narrower
ancies (Klonsky et al. 2002). DSM Axis II counterpart. It may be that the
Recently, several studies have used self- and broader constructs are the appropriate targets
other ratings to investigate systematic differ- for future development.
ences in the way individuals with NPD view In terms of the four phenotypic and taxo-
themselves in comparison with the way they nomic inconsistencies we noted, future research
are viewed by others. Miller et al. (2005) found will ultimately provide the most robust solu-
that in contrast to most personality disorders, tions. For now, our recommendations are as
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normal narcissism should be clarified. We do merely and inaccurately equates the term covert
not believe it is possible to define normal and narcissism with measures of narcissistic vulner-
pathological narcissism as opposite poles of a ability. In addition, concurrent overt and covert
single continuum because the absence of patho- characteristics are common to all forms of
logical narcissism is not equivalent to the pres- psychopathology, where diverse symptoms
ence of normal narcissism. Evidence to date are described as constellations of overt and
suggests that measures of narcissistic traits like covert behaviors, cognitions, affects, etc. Fi-
the NPI are often unrelated to (rather than nally, we view the term covert narcis-
negatively correlated with) measures of patho- sism as risking inaccurate communication. At
logical narcissism. Although normal and patho- times, grandiosity or vulnerability may be
logical narcissism may share similar relation- expressed covertly, but pathological narcis-
ships with general models of personality, they sism itself is quite detectable with appropriate
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tend to exhibit opposite patterns of correla- training.


tions with measures of well-being and malad- Fourth, we support representing the struc-
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

justment. Consistent with clinical theory, nor- ture of pathological narcissism using hierar-
mal narcissism may actually support adaptive chically organized dimensions (see Figure 2).
functioning, achievement motivation, and am- Narcissistic grandiosity and narcissistic vul-
bition, whereas pathological narcissism is asso- nerability are facets of pathological narcis-
ciated with significant impairments. sism, much like facet-level traits associated with
Second, future conceptions of pathologi- the FFM structure. A dimensional approach
cal narcissism must include both grandiosity to pathological narcissism can also be incor-
and vulnerability in the description and as- porated into evolving models of personality
sessment of phenotypic characteristics. Con- pathology that integrate categories and dimen-
tinued narrow operationalization of narcissis- sions (e.g., Krueger et al. 2008). In addition,
tic grandiosity greatly limits the clinical utility given diagnostic rules for DSM personality dis-
of the construct by contraindicating a diagnosis orders, dimensional conceptualization is also
of pathological narcissism if a patient presents more consistent with an emerging literature on
with low self-esteem, complains of subjective narcissistic disturbances in children and ado-
distress, or exhibits shameful affects. However, lescents (e.g., Bardenstein 2009; Beren 1998;
these aspects of narcissistic vulnerability are of- Freeman 2007; Kernberg 1989; Thomaes et al.
ten what promote pathologically narcissistic in- 2008a,b; Vizard 2008).
dividuals to seek treatment. The core feature Others may disagree with our recommenda-
of pathological narcissism is not grandiosity, tions, and the imminent arrival of DSM-V cer-
but rather defective self-regulation leading to tainly requires further discussion of the future
grandiose and vulnerable self and affect states. of NPD. Ronningstam (2009) has proposed al-
Third, the field should recognize that nar- ternative formulations for revising the DSM
cissistic grandiosity and narcissistic vulnerabil- NPD construct and criteria that broaden the in-
ity are expressed in overt and covert forms dicators of pathological narcissistic personality
within the same individual. In narcissistic pa- functioning, highlighting oscillation between
tients, for every act of overt grandiosity, there grandiose and vulnerable states. She proposes
is likely an underlying state of covert vulnera- NPD be characterized as “A pervasive pat-
bility, and for every act of overt vulnerability, tern of fluctuating and vulnerable self-esteem
there is likely a strong link to an underlying ranging from grandiosity and assertiveness to
aspect of covert grandiosity. Continued pheno- inferiority or insecurity, with self-enhancing
typic distinctions between overt and covert nar- and self-serving interpersonal behavior, and
cissism, be they typological or dimensional, are intense reactions to perceived threats, begin-
not supported by empirical evidence or clini- ning in early adulthood and present in a va-
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of the following” (Ronningstam 2009, p. 118). helps heighten awareness across disciplines in-
Ronningstam’s explicit criteria indeed incor- vestigating and treating narcissism. Advances
porate fluctuating and vulnerable self-esteem, in personality science (e.g., Eaton et al. 2009)
fluctuating empathic ability, overt and covert should provide additional integrative frame-
expressions of grandiosity and vulnerability, and works and methodologies to help resolve the
other characteristics not currently included in criterion problem and propel research forward.
DSM NPD, such as perfectionistic tenden- This is an important step for both classifica-
cies. Incorporation of characteristics highlight- tion and treatment, as we view pathological nar-
ing variability into a revised DSM NPD con- cissism as a significant clinical problem that is
ceptualization and criterion set would certainly likely underdetected using the current nosol-
shift NPD from its current narrow focus on ogy. Improved conceptualization and diagnosis
chronic grandiosity. will benefit patients, therapists, theorists, and
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investigators alike and will promote more ac-


curate research and more effective treatments.
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org

CONCLUSION This is certainly preferable to seeing the con-


Conceptions of personality disorders are cur- struct dropped from the nosology of personality
rently in flux, and the clinical and empirical lit- pathology, done in by poorly calibrated concep-
eratures on pathological narcissism and NPD tualizations across disciplines and a weak nomo-
suffer from significant phenotypic and taxo- logical net. At the risk of sounding grandiose,
nomic inconsistencies. Our review suggests that we believe clinical science and practice can in-
the field is now clearly aware of the crite- deed overcome these problems and that empir-
rion problem and is beginning to address it on ically rigorous and clinically useful conceptual-
multiple fronts. Acknowledging the problem is izations of pathological narcissism are certainly
the first step, and we hope the current review on the horizon.

SUMMARY POINTS
1. Narcissism is inconsistently defined and assessed across clinical psychology, psychiatry,
and social/personality psychology. This leads to a fundamental “criterion problem” where
there is no gold standard as to the meaning of the construct; thus, whether it is clinically
described or empirically measured, it can be difficult to synthesize among and across
clinical observations and empirical findings.
2. Narcissism is reflected in both normal adaptation and pathological personality func-
tioning. The most widely used measure of normal narcissistic personality traits is
the Narcissistic Personality Inventory (NPI). The NPI does not assess pathological
narcissism.
3. The clinical and empirical literatures recognize that pathological narcissism includes
two broad themes of dysfunction—narcissistic grandiosity and narcissistic vulnerability.
In contrast, with each DSM revision, NPD criteria have become increasingly narrow in
their focus on narcissistic grandiosity. This leads to the lowest prevalence rate among
DSM Axis II personality disorders, limited psychotherapy research, and a significant
disconnect with the much more common use of pathological narcissism as a diagnosis
in clinical practice. Revisions of NPD in DSM-V should include sufficient criteria to
permit diagnosis of NPD when either narcissistic grandiosity or narcissistic vulnerability
is predominantly observed in patient presentation.
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4. Distinguishing overt and covert narcissism as distinct types or phenotypes of narcissism


is clinically inaccurate. This distinction is simply about different modes of the expres-
sion of narcissistic grandiosity and narcissistic vulnerability. DSM NPD criteria; items
on various self-reports, interviews, and rating instruments assessing pathological narcis-
sism; and most certainly clinical conceptualizations of all forms of personality pathology
include a mix of overt elements (behaviors, expressed attitudes and emotions) and covert
experiences (cognitions, private feelings, motives, needs). Narcissistic patients virtually
always exhibit both covert and overt grandiosity and covert and overt vulnerability.
5. Future research should employ new assessment measures of pathological narcissism that
include grandiose and vulnerable characteristics. In addition, research indicates that for
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the assessment of pathological narcissism, it is critical to go beyond self-reports and


employ peer ratings whenever possible.
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6. The relationship between pathological narcissism and DSM NPD parallels the relation-
ship between psychopathy and DSM antisocial personality disorder. Like psychopathy,
pathological narcissism is a broader construct that is strongly related to its narrower DSM
Axis II counterpart. It may be that the broader constructs are the appropriate targets for
future development.

DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.

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