Pathological Narcissism and Narcissistic Personality Disorder
Pathological Narcissism and Narcissistic Personality Disorder
Pathological Narcissism and Narcissistic Personality Disorder
V I E W
E
R
S
Review in Advance first posted online
on December 14, 2009. (Changes may
C E
I N
A
D V A
Pathological Narcissism
and Narcissistic Personality
Disorder
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org
8.1
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org
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
E W
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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).
V I E
that even these traits are not ideally measured Individuals in the final subtype exhibited an E W
R
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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-
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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-
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org
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-
V I E
E W interviews for DSM personality disorders or haviorally through interpersonally exploitative
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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
V I E
ulation, affect dysregulation, and difficulties in defenses fail, narcissistic injury evokes shame, E W
R
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
Malignant
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org
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”
E W
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
(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).
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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
V I E
identified similar grandiose (Willful) and to its discrepant low-prevalence rate relative E W
R
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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
V I E
E W dominantly observed in patient presentation. distinguishes actual narcissistic patients is their
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org
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
V I E
ple favored a latent taxon (Fossati et al. 2005). challenging, the phenotypic and taxonomic E W
R
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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
V I E
E W terion. Zero-order correlations between NPD traits (Bernstein et al. 1997). Thus, investiga-
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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-
V I E
E W cal presentation. Most of the recent research riety of contexts as indicated by five or more
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
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.
V I E
E W
R
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
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.
LITERATURE CITED
Achenbach TM, Krukowski RA, Dumenci L, Ivanova MY. 2005. Assessment of adult psychopathology: meta-
analyses and implications of cross-informant correlations. Psychol. Bull. 131:361–82
Acton GS. 1998. Classification of psychopathology: the nature of language. J. Mind Behav. 19:243–56
Akhtar S. 2003. New Clinical Realms: Pushing the Envelope of Theory and Technique. Lanham, MD: Jason Aronson
Akhtar S, Thomson JA. 1982. Overview: narcissistic personality disorder. Am. J. Psychiatry 139:12–20
Am. Psychiatr. Assoc. 1980. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Assoc. 3rd ed.
Am. Psychiatr. Assoc. 1987. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Assoc. 3rd ed., rev. ed.
Am. Psychiatr. Assoc. 1994. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Assoc. 4th ed.
Am. Psychiatr. Assoc. 2000. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Assoc. 4th ed., rev. ed.
Ames DR, Rose P, Anderson CP. 2006. The NPI-16 as a short measure of narcissism. J. Res. Personal. 40:440–50
Ansell EB. 2006. An integrative two-dimensional model of adaptive and maladaptive narcissism. Presented at
Annu. Meet. Am. Psychol. Assoc., 114th, New Orleans, LA
Atlas GD, Them MA. 2008. Narcissism and sensitivity to criticism: a preliminary investigation. Curr. Psychol.
27:62–76
Austin JT, Villanova P. 1992. The criterion problem: 1917–1992. J. Appl. Psychol. 77:836–74
Bachar E, Hadar H, Shalev AY. 2005. Narcissistic vulnerability and the development of PTSD: a prospective
V I E
E W study. J. Nerv. Ment. Dis. 193:762–65
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
Bagby RM, Sellbom M, Costa PT Jr, Widiger TA. 2008. Predicting Diagnostic and Statistical Manual of Mental
Disorders-IV personality disorders with the Five-Factor Model of Personality and the Personality Psy-
chopathology Five. Personal. Ment. Health 2:55–69
Ball SA, Rounsaville BJ, Tennen H, Kranzler HR. 2001. Reliability of personality disorder symptoms and
personality traits in substance-dependent inpatients. J. Abnorm. Psychol. 110:341–52
Bardenstein KK. 2009. The cracked mirror: features of narcissistic personality disorder in children. Psychiatr.
Ann. 39:147–55
Beren P. 1998. Narcissistic Disorders in Children and Adolescents. London: Jason Aronson
Bernstein DP, Kasapis C, Bergman A, Weld E. 1997. Assessing Axis II disorders by informant interview.
J. Personal. Disord. 11:158–67
Besser A, Priel B. 2009. Emotional responses to a romantic partner’s imaginary rejection: the roles of attach-
ment anxiety, covert narcissism, and self-evaluation. J. Personal. 77:287–325
Block J. 1978. The Q-Sort Method in Personality Assessment and Psychiatric Research. Palo Alto, CA: Consult.
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
Psychol. Press
Broucek FJ. 1982. Shame and its relationship to early narcissistic developments. Int. J. Psychoanal. 63:369–78
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org
Brown RP, Budzek K, Tamborski M. 2009. On the meaning and measure of narcissism. Personal. Soc. Psychol.
Bull. 35:951–64
Brown RP, Zeigler-Hill V. 2004. Narcissism and the nonequivalence of self-esteem measures: a matter of
dominance? J. Res. Personal. 38:585–92
Bursten B. 1973. Some narcissistic personality types. Int. J. Psychoanal. 54:287–300
Bushman BJ, Baumeister RF. 1998. Threatened egotism, narcissism, self-esteem, and direct and displaced
aggression: Does self-love or self-hate lead to violence? J. Personal. Soc. Psychol. 75:219–29
Buss DM, Chiodo LM. 1991. Narcissistic acts in everyday life. J. Personal. 59:179–215
Cain NM, Pincus AL, Ansell EB. 2008. Narcissism at the crossroads: phenotypic description of patho- Interdisciplinary review
logical narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. of pathological
Clin. Psychol. Rev. 28:638–56 narcissism.
Campbell WK. 2001. Is narcissism really so bad? Psychol. Inq. 12:214–16
Campbell WK, Bonacci AM, Shelton J, Exline JJ, Bushman BJ. 2004. Psychological entitlement: interpersonal
consequences and validation of a self-report measure. J. Personal. Assess. 83:29–45
Campbell WK, Bosson JK, Goheen TW, Lakey CE, Kernis MH. 2007. Do narcissists dislike themselves
“deep down inside”? Psychol. Sci. 18:227–29
Casillas A, Schulz EM, Robbins SB, Santos PJ, Lee RM. 2006. Exploring the meaning of motivation across
cultures: IRT analyses of the goal instability scale. J. Career Assess. 14:472–89
Chatham PM, Tibbals CJ, Harrington ME. 1993. The MMPI and the MCMI in the evaluation of narcissism
in a clinical sample. J. Personal. Assess. 60:239–51
Clark LA. 1993. Schedule for Maladaptive and Adaptive Personality (SNAP). Minneapolis, MN: Univ. Minn.
Press
Clark LA. 2007. Assessment and diagnosis of personality disorder: perennial issues and an emerging recon-
ceptualization. Annu. Rev. Psychol. 58:227–57
Clemence AJ, Perry JC, Plakun EM. 2009. Narcissistic and borderline personality disorders in a sample of
treatment refractory patients. Psychiatr. Ann. 39:175–84
Clifton A, Turkheimer E, Oltmanns TF. 2004. Contrasting perspectives on personality problems: descriptions
from the self and others. Personal. Individ. Diff. 36:1499–514
Clifton A, Turkheimer E, Oltmanns TF. 2005. Self- and peer perspectives on pathological personality traits
and interpersonal problems. Psychol. Assess. 17:123–31
Clifton A, Turkheimer E, Oltmanns TF. 2007. Improving assessment of personality disorder traits through
social network analysis. J. Personal. 75:1007–32
Cooper AM. 1981. Narcissism. In American Handbook of Psychiatry, ed. S Arieti, H Keith, H Brodie, 4:297–316.
New York: Basic Books
Cooper AM. 1988. The narcissistic-masochistic character. In Masochism: Current Psychoanalytic Perspectives, ed.
R Glick, D Meyers, pp. 117–38. Hillsdale, NJ: Analytic
Cooper AM. 2005. The Quiet Revolution in American Psychoanalysis: Selected Works of Arnold M. Cooper.
V I E
New York: Brunner-Routledge E W
R
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
Disord. 17:188–207
Dimaggio G, Procacci M, Nicolò G, Popolo R, Semerari A, et al. 2007. Poor metacognition in narcissistic and
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org
avoidant personality disorders: four psychotherapy patients analyzed using the metacognition assessment
scale. Clin. Psychol. Psychother. 14:386–401
Doidge N, Simon B, Brauer L, Grant DC, First M, et al. 2002. Psychoanalytic patients in the U.S., Canada, and
Australia: I. DSM-III-R disorders, indications, previous treatment, medications, and length of treatment.
J. Am. Psychoanal. Assoc. 50:575–614
Eaton NR, South SC, Krueger RF. 2009. The Cognitive-Affective Processing System (CAPS) approach to
the concept of personality disorder: integrating clinical and social-cognitive research. J. Res. Personal.
43:208–217
Ellis H. 1898. Auto-eroticism: a psychological study. Alienes Neurol. 19:260–99
Emmons RA. 1984. Factor analysis and construct validity of the narcissistic personality inventory. J. Personal.
Assess. 48:291–300
Emmons RA. 1987. Narcissism: theory and measurement. J. Personal. Soc. Psychol. 52:11–17
Farwell L, Wohlwend-Lloyd R. 1998. Narcissistic processes: optimistic expectations, favorable self-
evaluations, and self-enhancing attributions. J. Personal. 66:65–83
Fiedler ER, Oltmanns TF, Turkheimer E. 2004. Traits associated with personality disorders and adjustment
to military life: predictive validity of self and peer reports. Mil. Med. 169:207–11
First MB, Spitzer RL, Gibbon M, Williams JBW. 1995. Structured Clinical Interview for DSM-IV. New York:
N.Y. State Psychiatr. Inst.
Fiscalini J. 1993. The psychoanalysis of narcissism: an interpersonal view. In Narcissism and the Interper-
sonal Self. Personality, Psychopathology, and Psychotherapy: Theoretical and Clinical Perspectives, ed. J Fiscalini,
A Gray, pp. 318–48. New York: Columbia Univ. Press
Fossati A, Beauchaine TP, Grazioli F, Carretta I, Cortinovis F, Maffei C. 2005. A latent structure analysis
of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, narcissistic personality disorder
criteria. Compr. Psychiatry 46:361–67
Foster JD, Campbell WK. 2007. Are there such things as “narcissists” in social psychology? A taxometric
analysis of the narcissistic personality inventory. Personal. Individ. Differ. 43:1321–32
Foster JD, Trimm RF IV. 2008. On being eager and uninhibited: narcissism and approach-avoidance motiva-
tion. Person. Soc. Psychol. Bull. 34:1004–17
Freeman A. 2007. The narcissistic child: when a state becomes a trait. In Personality Disorders in Childhood and
Adolescence, ed. A Freeman, MA Reinecke, pp. 385–427. Hoboken, NJ: Wiley
Freud S. 1914/1957. On narcissism: an introduction. In The Standard Edition of the Complete Psychological Works
of Sigmund Freud, ed. J Strachey, 7:66–102. London: Hogarth
Gabbard GO. 1989. Two subtypes of narcissistic personality disorder. Bull. Menninger Clin. 53:527–32
Gabbard GO. 1998. Transference and countertransference in the treatment of narcissistic patients. See
Ronningstam 1998, pp. 125–45
Gabbard GO. 2009. Transference and countertransference: developments in the treatment of narcissistic
V I E
E W personality disorder. Psychiatr. Ann. 39:129–36
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
Gersten SP. 1991. Narcissistic personality disorder consists of two distinct subtypes. Psychiatr. Times 8:25–26
Guilé J, Sayegh L, Bergeron L, Fortier H, Goldberg D, Gunderson J. 2004. Initial reliability of the Diagnostic
Interview for Narcissism adapted for preadolescents: Parent Version (P-DIN). Can. Child Adolesc. Psychiatr.
Rev. 13:74–80
Gunderson JG, Ronningstam EF, Bodkin A. 1990. The diagnostic interview for narcissistic patients. Arch.
Gen. Psychiatry 47:676–80
Handler L, Hilsenroth MJ. 2006. Rorschach assessment of narcissistic personality disorder. In Rorschach
Assessment of the Personality Disorders, ed. SK Huprich, pp. 223–62. Mahwah, NJ: Erlbaum
Hare RD, Neumann CS. 2008. Psychopathy as a clinical and empirical construct. Annu. Rev. Clin. Psychol.
4:217–46
Harkness AR, McNulty JL. 1994. The Personality Psychopathology Five (PSY-5): issues from the pages of a
diagnostic manual instead of a dictionary. In Differentiating Normal and Abnormal Personality, ed. S Strack,
M Lorr, pp. 291–315. New York: Springer
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
Hatcher RL, Rogers DT. 2009. Development and validation of a measure of interpersonal strengths: the
inventory of interpersonal strengths. Psychol. Assess. In press
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org
Heisel MJ, Links PS, Conn D, van Reekum R, Flett GL. 2007. Narcissistic personality and vulnerability to
late-life suicidality. Am. J. Geriatr. Psychiatr. 15:734–41
Hendin HM, Cheek JM. 1997. Assessing hypersensitive narcissism: a reexamination of Murray’s narcism scale.
J. Res. Personal. 31:588–99
Hicklin J, Widiger TA. 2000. Convergent validity of alternative MMPI-2 personality disorder scales. J. Personal.
Assess. 75:502–18
Hilsenroth MJ, Handler L, Blais MA. 1996. Assessment of narcissistic personality disorder: a multi-method
review. Clin. Psychol. Rev. 16:655–83
Horowitz M. 2009. Clinical phenomenology of narcissistic pathology. Psychiatr. Ann. 39:124–28
Horton RS, Bleau G, Drwecki B. 2006. Parenting narcissus: What are the links between parenting and
narcissism? J. Personal. 74:345–76
Hunt W. 1995. The diffident narcissist: a character-type illustrated in The Beast in the Jungle by Henry James.
Int. J. Psychoanal. 76:1257–67
Huprich SK, Bornstein RF. 2007. An overview of issues related to categorical and dimensional models of
personality disorders assessment. J. Personal. Assess. 89:3–15
Hyler SE. 1994. Personality Diagnostic Questionnaire-4. New York: N.Y. State Psychiatr. Inst. Unpubl. test
Kernberg OF. 1967. Borderline personality organization. J. Am. Psychoanal. Assoc. 15:641–85
Kernberg OF. 1984. Severe Personality Disorders: Psychotherapeutic Strategies. New Haven: Yale Univ. Press
Kernberg OF. 1998. Pathological narcissism and narcissistic personality disorder: theoretical background and
diagnostic classification. See Ronningstam 1998, pp. 29–51
Kernberg OF. 2007. The almost untreatable narcissistic patient. J. Am. Psychoanal. Assoc. 55:503–39
Kernberg OF. 2009. Narcissistic personality disorders: part 1. Psychiatr. Ann. 39:105–67
Kernberg PF. 1989. Narcissistic personality disorder in childhood. Psychiatr. Clin. North Am. 12:671–94
Klein DN. 2003. Patients’ versus informants’ reports of personality disorders in predicting 7-1/2-year outcome
in outpatients with depressive disorders. Psychol. Assess. 15:216–22
Klein MH, Benjamin LS, Rosenfeld R, Treece C. 1993. The Wisconsin Personality Disorders Inventory:
development, reliability, and validity. J. Personal. Disord. 7:285–303
Klonsky ED, Oltmanns TF, Turkheimer E. 2002. Informant-reports of personality disorder: relation Reviews research on
to self-reports and future research directions. Clin. Psychol. Sci. Pract. 9:300–11 agreement of self- and
Kohut H. 1968. The psychoanalytic treatment of narcissistic personality disorders: outline of a systematic informant reports of
approach. Psychoanal. Study Child. 23:86–113 personality disorders
demonstrating low
Kohut H. 1971. The Analysis of the Self. New York: Int. Univ. Press
convergence for NPD
Kohut H. 1977. The Restoration of the Self. New York: Int. Univ. Press
ratings.
Kohut H, Wolf ES. 1978. The disorders of the self and their treatment: an outline. Int. J. Psychoanaly. 59:413–25
Krueger RF, Skodol AE, Livesley WJ, Shrout PE, Huang Y. 2008. Synthesizing dimensional and categor-
ical approaches to personality disorders: refining the research agenda for DSM-V Axis II. In Dimen-
sional Approaches to Diagnostic Classification: A Critical Appraisal, ed. JE Helzer, HC Kraemer, H Chmura,
V I E
RF Krueger, H Wittchen, pp. 85–99. Washington, DC: Am. Psychiatr. Assoc. E W
R
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
Kubarych TS, Deary IJ, Austin EJ. 2004. The Narcissistic Personality Inventory: factor structure in a non-
clinical sample. Personal. Individ. Differ. 36:857–72
Lee K, Ashton MC. 2004. Psychometric properties of the HEXACO Personality Inventory. Multivar. Behav.
Res. 39:329–58
Lenzenweger MF, Johnson MD, Willett JB. 2004. Individual growth curve analysis illuminates stability and
change in personality disorder features: the longitudinal study of personality disorders. Arch. Gen. Psychi-
atry 61:1015–24
Levy KN, Chauhn P, Clarkin JF, Wasserman RH, Reynoso JS. 2009. Narcissistic pathology: empirical
approaches. Psychiatr. Ann. 39:203–13
Review of narcissistic Levy KN, Reynoso JS, Wasserman RH, Clarkin JF. 2007. Narcissistic personality disorder. In Per-
personality disorder sonality Disorders: Toward the DSM-V, ed. W O’Donohue, KA Fowler, SO Lilienfeld, pp. 233–77.
(NPD). Thousand Oaks, CA: Sage
Livesley WJ. 2006. The Dimensional Assessment of Personality Pathology (DAPP) approach to personality
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
Millon T, Millon C, Davis R. 1997. MCMI-III Manual. Minneapolis, MN: Nat. Comp. Syst. 2nd ed.
Morey LC. 1991. The Personality Assessment Inventory Professional Manual. Odessa, FL: Psychol. Assess. Resourc.
Morey LC. 1996. An Interpretive Guide to the Personality Assessment Inventory. Odessa, FL: Psychol. Assess.
Resourc.
Morey LC, Ochoa ES. 1989. An investigation of adherence to diagnostic criteria: clinical diagnosis of the
DSM-III personality disorders. J. Personal. Disord. 3:180–92
Morf CC. 2006. Personality reflected in a coherent idiosyncratic interplay of intra- and interpersonal self-
regulatory processes. J. Personal. 74:1527–56
Morf CC, Rhodewalt F. 2001. Unraveling the paradoxes of narcissism: a dynamic self-regulatory processing
model. Psychol. Inq. 12:177–96
Nurse AR. 1998. The dependent/narcissistic couple. In The Disordered Couple, ed. J Carlson, L Sperry,
pp. 315–31. Philadelphia, PA: Brunner/Mazel
Oldham JM, Morris LB. 1995. The New Personality Self-Portrait: Why You Think, Work, Love, and Act the Way
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
Raskin RN, Terry H. 1988. A principal-components analysis of the Narcissistic Personality Inventory and
further evidence of its construct validity. J. Personal. Soc. Psychol. 54:890–902
Rathvon N, Holmstrom RW. 1996. An MMPI-2 portrait of narcissism. J. Personal. Assess. 66:1–19
Rhodewalt F, Morf CC. 1995. Self and interpersonal correlates of the narcissistic personality inventory: a
review and new findings. J. Res. Personal. 29:1–23
Robbins SB. 1989. Validity of the superiority and goal instability scales as measures of defects in the self.
J. Personal. Assess. 53:122–32
Robbins SB, Patton MJ. 1985. Self-psychology and career development: construction of the superiority and
goal instability scales. J. Couns. Psychol. 32:221–31
Ronningstam EF, ed. 1998. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Washington,
Review of narcissistic DC: Am. Psychiatr. Assoc.
personality disorder Ronningstam EF. 2005a. Identifying and Understand the Narcissistic Personality. New York: Oxford Univ. Press
(NPD).
Ronningstam EF. 2005b. Narcissistic personality disorder: a review. See Maj et al. 2005, pp. 277–327
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
Ronningstam EF. 2009. Narcissistic personality disorder: facing DSM-V. Psychiatr. Ann. 39:111–21
Proposes revisions to Ronningstam E, Gunderson J. 1988. Narcissistic traits in psychiatric patients. Compr. Psychiatry 29:545–49
Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org
NPD for DSM-V. Ronningstam E, Gunderson JG. 1990. Identifying criteria for narcissistic personality disorder. Am. J. Psychiatry
147:918–22
Ronningstam E, Gunderson J. 1991. Differentiating borderline personality disorder from narcissistic person-
ality disorder. J. Personal. Disord. 5:225–32
Ronningstam E, Gunderson J, Lyons M. 1995. Changes in pathological narcissism. Am. J. Psychiatry 152:253–
57
Ronningstam E, Weinberg I, Maltsberger JT. 2008. Eleven deaths of Mr. K.—contributing factors to suicide
in narcissistic personalities. Psychiatry 71:169–82
Rosenfeld H. 1987. Impasse and Interpretation: Therapeutic and Anti-Therapeutic Factors in the Psychoanalytic
Treatment of Psychotic, Borderline, and Neurotic Patients, Vol. 1. New York: Tavistock/Routledge
Q-factor analyses of the Russ E, Shedler J, Bradley R, Westen D. 2008. Refining the construct of narcissistic personality
SWAP-II validating disorder: diagnostic criteria and subtypes. Am. J. Psychiatry 165:1473–81
narcissistic grandiosity Ryan KM, Weikel K, Sprechini G. 2008. Gender differences in narcissism and courtship violence in dating
and narcissistic
couples. Sex Roles 58:802–13
vulnerability.
Samuel DB, Widiger TA. 2008. Convergence of narcissism measures from the perspective of general
personality functioning. Assessment 15:364–74
Saulsman LM, Page AC. 2004. The five-factor model and personality disorder empirical literature: a meta-
Correlates five
analytic review. Clin. Psychol. Rev. 23:1055–85
narcissism measures
Schotte C, De Doncker D. 1996. ADP-IV Questionnaire: Manual and Norms. Antwerp, Belgium: Univ. Hosp.
with the NEO-
Antwerp
Personality Inventory
and demonstrates Sedikides C, Rudich EA, Gregg AP, Kumashiro M, Rusbult C. 2004. Are normal narcissists psychologically
marked variability of healthy? Self-esteem matters. J. Personal. Soc. Psychol. 87:400–16
five-factor model Shea MT, Pilkonis PA, Beckham E, Collins JF, Elkin I, Sotsky SM. 1990. Personality disorders and treatment
profiles across outcome in the NIMH Treatment of Depression Collaborative Research Program. Am. J. Psychiatry
instruments. 147:711–18
Shedler J, Westen D. 2004. Refining personality disorder diagnosis: integrating science and practice. Am. J.
Psychiatry 161:1350–65
Shedler J, Westen D. 2007. The Shedler-Westen Assessment Procedure (SWAP): making personality diagnosis
clinically meaningful. J. Personal. Assess. 89:41–55
Simms LJ, Clark LA. 2006. The Schedule for Nonadaptive and Adaptive Personality (SNAP): a dimensional
measure of traits relevant to personality and personality pathology. See Strack 2006, pp. 431–50
Simon RI. 2002. Distinguishing trauma-associated narcissistic symptoms from posttraumatic stress disorder:
a diagnostic challenge. Harv. Rev. Psychiatry 10:28–36
Smolewska K, Dion KL. 2005. Narcissism and adult attachment: a multivariate approach. Self Ident. 4:59–68
Somwaru DP, Ben-Porath YS. 1995. Development and reliability of MMPI-2-based personality disorder scales.
Presented at Annu. Workshop Sympos. Recent Develop. Use MMPI-2 and MMPI-A, 30th, St. Petersburg
V I E
E W Beach, FL
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
Stone MH. 1998. Normal narcissism: an etiological and ethological perspective. See Ronningstam 1998,
pp. 7–28
Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, et al. 2008. Prevalence, correlates, disability, and
comorbidity of DSM-IV narcissistic personality disorder: results from the Wave 2 National Epidemiologic
Survey on Alcohol and Related Conditions. J. Clin. Psychiatry 69:1033–45
Strack S, ed. 2006. Differentiating Normal and Abnormal Personality. New York: Springer. 2nd ed.
Thomaes S, Bushman BJ, Stegge H, Olthof T. 2008a. Trumping shame by blasts of noise: narcissism, self-
esteem, shame, and aggression in young adolescents. Child Dev. 79:1792–801
Thomaes S, Stegge H, Bushman BJ, Olthof T, Denissen J. 2008b. Development and validation of the childhood
narcissism scale. J. Personal. Assess. 90:382–91
Thomas C, Turkheimer E, Oltmanns TF. 2003. Factorial structure of pathological personality as evaluated
by peers. J. Abnorm. Psychol. 112:81–91
Trull TJ. 1992. DSM-III-R personality disorders and the five-factor model of personality: an empirical com-
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
Psychol. 1:355–80
Vizard E. 2008. Emerging severe personality disorder in childhood. Child Psychiatry 7:389–94
Wallace HM, Baumeister RF. 2002. The performance of narcissists rises and falls with perceived opportunity
for glory. J. Personal. Soc. Psychol. 82:819–34
Wallace HM, Ready CB, Weitenhagen E. 2009. Narcissism and task persistence. Self Ident. 8:78–93
Watson PJ. 2005. Complexity of narcissism and a continuum of self-esteem regulation. See Maj et al. 2005,
pp. 336–38
Watson PJ, Little T, Sawrie SM, Biderman MD. 1992. Measures of the narcissistic personality: complexity of
relationships with self-esteem and empathy. J. Personal. Disord. 6:434–49
Watson PJ, Trumpeter N, O’Leary BJ, Morris RJ, Culhane SE. 2005–2006. Narcissism and self-esteem in
the presence of imagined others: supportive versus destructive object representations and the continuum
hypothesis. Imag. Cogn. Personal. 25:253–68
Watson PJ, Varnell SP, Morris RJ. 1999–2000. Self-reported narcissism and perfectionism: an ego-
psychological perspective and the continuum hypothesis. Imag. Cogn. Personal. 19:59–69
Westen D. 1997. Divergences between clinical and research methods for assessing personality disorders:
implications for research and the evolution of Axis II. Am. J. Psychiatry 154:895–903
Westen D, Arkowitz-Westen L. 1998. Limitations of Axis II in diagnosing personality pathology in clinical
practice. Am. J. Psychiatry 155:1767–71
Westen D, Shedler J. 1999. Revising and assessing Axis II, part I: developing a clinically and empirically valid
assessment method. Am. J. Psychiatry 156:258–72
Westen D, Shedler J. 2007. Personality diagnosis with the Shedler-Westen Assessment Procedure (SWAP):
integrating clinical and statistical measurement and prediction. J. Abnorm. Psychol. 116:810–22
Westen D, Shedler J, Bradley R. 2006. A prototype approach to personality disorder diagnosis. Am. J. Psychiatry
163:846–56
Widiger TA, Coker LA. 2002. Assessing personality disorders. In Clinical Personality Assessment: Practical
Approaches, ed. JN Butcher, 2:407–34. New York: Oxford Univ. Press
Widiger TA, Mangine S, Corbitt EM, Ellis CG, Thomas GV. 1995. Personality Disorder Interview-IV. A
Semistructured Interview for the Assessment of Personality Disorders. Professional Manual. Odessa, FL: Psychol.
Assess. Res.
Widiger TA, Mullins-Sweatt SN. 2005. Categorical and dimensional models of personality disorders. In The
American Psychiatric Publishing Textbook of Personality Disorders, ed. JM Oldham, AE Skodol, DS Bender,
pp. 35–53. Arlington, VA: Am. Psychiatr. Publ.
Widiger TA, Trull TJ. 2007. Plate tectonics in the classification of personality disorder: shifting to a dimensional
model. Am. Psychol. 62:71–83
Wiggins JS 1973. Personality and Prediction: Principles of Personality Assessment. Reading, MA: Addison-Wesley
Wink P. 1991. Two faces of narcissism. J. Personal. Soc. Psychol. 61:590–97
V I E
Wink P. 1992. Three narcissism scales for the California Q-set. J. Personal. Assess. 58:51–66 E W
R
E
C
A
D V A N
Changes may still occur before final publication online and in print.
ANRV407-CP06-08 ARI 17 November 2009 21:25
Wink P. 1996. Narcissism. In Personality Characteristics of the Personality Disordered, ed. CG Costello,
pp. 146–72. New York: Wiley
Summarizes the Wink P, Dillon M, Fay K. 2005. Spiritual seeking, narcissism, and psychotherapy: How are they
author’s important related? J. Sci. Study Relig. 44:143–58
factor-analytic and Wink P, Donahue K. 1997. The relation between two types of narcissism and boredom. J. Res. Personal.
Q-sort research 31:136–40
validating narcissistic
Wright AGC, Lukowitsky MR, Pincus AL. 2008. The hierarchical factor structure of the pathological narcissism
grandiosity and
inventory (PNI). Presented at Annu. Meet. Am. Psychol. Assoc., 116th, Boston, MA
narcissistic
vulnerability.
Zanarini MC, Frankenburg FR, Chauncey DL, Gunderson JG. 1987. The Diagnostic Interview for Personality
Disorders: interrater and test-retest reliability. Comp. Psychiatry 28:467–80
Zeigler-Hill V. 2006. Discrepancies between implicit and explicit self-esteem: implications for narcissism and
self-esteem instability. J. Personal. 74:119–43
Zimmerman M, Rothschild L, Chelminski I. 2005. The prevalence of DSM-IV personality disorders in
by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only.
V I E
E W
R
·
S
E
C
A
D V A N
Changes may still occur before final publication online and in print.