research articles on narcissistic personality disorder

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• LEARNING OBJECTIVES
• DECLARATION OF INTEREST

Historical review of the concept of narcissism

Narcissism, narcissistic personality disorder and the dsm, diagnosis of narcissistic personality disorder, epidemiology of narcissistic personality disorder, aetiology of pathological narcissism and narcissistic personality disorder, challenges in the management and treatment of narcissistic personality disorder, treatments for narcissistic personality disorder, conclusions, current understanding of narcissism and narcissistic personality disorder.

Published online by Cambridge University Press:  05 July 2018

This article reviews historical contributions to the conceptualisation of narcissism and narcissistic personality disorder (NPD), including its evolution as a clinical diagnosis within the DSM classification of mental disorders. It discusses the epidemiology and aetiology of NPD, noting that empirical studies of both are limited. The challenges of managing patients with prominent narcissistic traits are presented, and the psychological therapies specifically designed for the treatment of patients with NPD are summarised.

• Understand different models of narcissism

• Understand the epidemiology, comorbidity and theories of aetiology of NPD

• Know how to manage and treat patients with pathological narcissism and NPD

The legend of Narcissus in Greek mythology, from which the term narcissism derives, has become one of the most prototypical myths of modern times. The most popular version of the story is by Ovid in his work Metamorphoses , in which Echo, a mountain nymph, encounters Narcissus, a beautiful young man, who rejects her advances. Heartbroken, Echo lives out her life in desolation until only an echo of her voice remains. Nemesis, the goddess of revenge, punishes Narcissus by luring him to a pool of water, in which he catches an image of himself and, not realising it is his own reflection, falls in love with it. The more he gazes, the more infatuated he becomes. Eventually he realises that his love can never be reciprocated and, condemned to the same fate that he had inflicted on Echo, he remains in despair, fixated by his image until death; Echo, at his side, repeats his last words.

Narcissism has become a defining feature of the modern era: interest in the concept has captured the imagination of the public, media and literature. In the 1970s the American journalist Tom Wolfe coined the phrase ‘the “Me” decade’ to describe the rise in celebration of the self (Wolfe Reference Wolfe 1976 ) and the American historian and social critic Christopher Lasch published The Culture of Narcissism , in which he explores the rise of narcissistic entitlement and decadence (Lasch Reference Lasch 1979 ). These popularised texts have been paralleled by a growing body of academic interest and empirical research, particularly in the fields of psychology, social science and cultural studies. Within psychiatry, the concept of narcissism has evolved from early psychoanalytic theorising to its official inclusion as a personality disorder in psychiatric nomenclature.

Psychoanalytic models of narcissism

Havelock Ellis was the first theoretician to use the Narcissus myth to describe narcissism as a clinical entity, in his description of states of intense autoerotism or preoccupation with one's own sexual body (Ellis Reference Ellis 1898 ). Psychoanalysts subsequently elaborated the construct of narcissism as a personality characteristic of vanity and self-love that is not exclusively sexual, nor confined to the realm of pathology, but a normal part of human development. Otto Rank ( Reference Rank 1911 ) wrote the first psychoanalytic paper focusing on narcissism, and this was followed by the publication of Freud's now classic text On Narcissism (Freud Reference Freud and Strachey 1914 ). These papers highlighted the defensive function of narcissism in protecting the individual from feelings of low self-worth and self-esteem, as well as conceptualising narcissism as a dimensional psychological state that ranged from normal to pathological, forerunning the ideas of more contemporary personality trait theorists (Levy Reference Levy, Ellison, Reynoso, Campbell and Miller 2011 ). Later psychoanalysts expanded on the idea of a narcissistic personality type, for example in Wilhelm Reich's ‘phallic–narcissistic character’ (Reich Reference Reich 1933 ), Karen Horney's subdivisions of ‘aggressive–expansive’, ‘perfectionist’ and ‘arrogant–vindictive’ (Horney Reference Horney 1939 ) and Donald Winnicott's notions of the true and false self (Winnicott Reference Winnicott 1960 ).

However, the respective (and conflicting) theories of the psychoanalysts Heinz Kohut and Otto Kernberg might be said to have exerted the most influence on modern conceptualisations of narcissism and on shaping the construct of narcissistic personality disorder (NPD). Kohut's self-psychology approach (Kohut Reference Kohut 1971 ) offers the ‘deficit model’ of narcissism, which asserts that pathological narcissism originates in childhood as a result of the failure of parents to empathise with their child. The normal integration of the ‘grandiose self’ and ‘idealised parental imago’ does not occur and grandiose omnipotence emerges as a defence against fragmentation of the self. Narcissistic individuals are prone to experiencing emptiness and depression in response to narcissistic injury. By contrast, Kernberg's object relations approach (Kernberg Reference Kernberg 1984 ) emphasises aggression and conflict in the psychological development of narcissism, focusing on the patient's aggression towards and envy of others. In this ‘conflict model’, early childhood experiences of cold, indifferent or aggressive parental figures push the child to develop feelings of specialness as a retreat. These feelings evolve into a pathological grandiose self-structure, which defends against the child's rage at his inability to internalise good objects. In pathologically narcissistic individuals, primitive defence mechanisms of idealisation, denigration and splitting predominate, the capacity for sadness, guilt and mourning is lacking, and the main affects are shame, envy and aggression.

Social and personality models of narcissism

These psychoanalytic theories, based on clinical work with narcissistic patients, were paralleled by developments in social critical theory. Following the sociologist and philosopher Theodore Adorno's ( Reference Adorno 1968 ) proposition that narcissism was a result of the collective ego's defensive response to industrialisation and the changing economic and social structure of society, writers such as Wolfe and Lasch documented the rise of the cult of the individual, self-expression, self-admiration and materialism as key to economic prosperity, happiness and success, away from traditional American societal values anchored in family and community. More recently, accumulated empirical research findings from studies that document rising rates of narcissism in American college students between 1979 and 2006 revealed an ‘epidemic of narcissism’ within American society (Twenge Reference Twenge and Campbell 2009 ). Cultural studies have suggested that the USA is seen as a more narcissistic society, in which individualism, professional success, fame and material wealth are celebrated, in contrast to Eastern cultures in Asia and the Middle East, which promote collectivism and more shared parenting practices and where self-reports of narcissistic traits have been shown to being lower than in Western countries such as the USA (Foster Reference Foster, Campbell and Twenge 2003 ).

The field of social–personality psychology and its research on assessment and factor analysis has increasingly influenced contemporary theories regarding narcissism, such as its links to shame, victimhood and aggression. There is now a large empirical literature in the field that conceptualises narcissism as a normative personality trait, which can be adaptive and maladaptive. Most of this research has relied on the Narcissistic Personality Inventory (Raskin Reference Raskin and Hall 1979 ), the instrument most frequently used to measure narcissism, although it has been criticised for assessing adaptive components such as self-esteem, well-being and leadership at the same time as maladaptive features such as grandiosity and entitlement.

Although the cognitive–behavioural literature on narcissism is relatively sparse in comparison with that on psychoanalytic and psychodynamic approaches, theoreticians and clinicians within the cognitive–behavioural tradition have more recently applied this approach to the study of NPD, in their emphasis on the social learning of core beliefs or self-schemas. Theodore Millon's ( Reference Millon 1981 ) social learning perspective proposes that children learn about themselves and others from their parents’ behaviour, and in narcissistic individuals, beliefs about specialness and entitlement are thought to stem from early parental overindulgence. Others have pointed to parental abuse and neglect as instrumental in the development of pathological narcissism. Beck described dysfunctional core beliefs or schemas, stemming from early experiences of adverse parenting, associated with NPD that lead the person to be self-indulgent, demanding and aggressive, but also highlighted how these individuals often presented with symptoms of depression (Beck Reference Beck and Freeman 1990 ). Cognitive theorists such as Jeffrey Young (Young Reference Young, Klosko and Weishaar 2003 ) have expanded Beck & Freeman’s ( Reference Beck and Freeman 1990 ) original theories of core distorted beliefs and dysfunctional schemas via integration with interpersonal and gestalt perspectives and a particular focus on the role of negative early experiences and affects in the aetiology and treatment of NPD.

The widespread use of the concept of pathological narcissism as a distinct personality type by clinicians influenced by psychoanalysts such as Kernberg and Kohut, as well as psychologists such as Millon, led to the introduction of narcissistic personality disorder into the third edition of the DSM (DSM-III) in 1980 (American Psychiatric Association 1980 ). The NPD construct was further refined and modified as it evolved through DSM-III-R ( 1987 ) and DSM-IV ( 1994 ) on the basis of the empirical findings of an increasing number of psychological studies identifying narcissism as a personality trait. However, these shifts in the diagnostic criteria for the disorder were criticised for losing some of the more dynamic variables present in its phenomenological manifestations. Authors such as Cain et al ( Reference Cain, Pincus and Ansell 2008 ) noted that DSM-IV predominantly focused on the disorder's grandiose features and did not adequately capture the underlying vulnerability that is evident in many narcissistic individuals.

Inconsistencies in the conceptualisation of narcissism, including differences in describing its nature (normal, pathological), phenotype (grandiosity, vulnerability), expression (overt, covert) and structure (category, dimension, prototype), were reflected in the limited descriptions of these areas in the DSM-IV definition of NPD (Pincus Reference Pincus and Lukowitsky 2010 ). Another criticism levelled at NPD as defined by the DSM is that it is one of the rarer personality disorders found in community and clinical samples, despite the widespread clinical observation of a much higher prevalence of problematic narcissistic traits in patients with personality difficulties. These shortcomings were to be ameliorated in a new model of personality disorder as a categorical–dimensional hybrid, which was intended to become the official approach to the diagnosis of all personality pathology and disorders in DSM-5 (American Psychiatric Association, 2013 ). This model is based on the assessment of core aspects of personality functioning and pathological personality traits and has received much support from researchers and clinicians in the personality disorder field. One of the main goals of the new classification in DSM-5 was to increase the validity of mental disorder diagnoses by incorporating dimensional assessment, which is particularly relevant to NPD, given that narcissism occurs on a spectrum of severity from normal to pathological. However, disagreements within the personality disorder research community, as well as the American Psychiatric Association, resulted in this new model of personality disorder not being adopted by DSM-5, although it has been placed in Section III of the manual (‘Emerging measures and models’) as an area for future study (Skodol Reference Skodol, Bender and Morey 2014 ). The diagnostic criteria for NPD in DSM-5 (American Psychiatric Association 2013 ) therefore remain identical to those in DSM-IV ( Box 1 ).

BOX 1 DSM-5 criteria for NPD

– Grandiosity and self-importance

– Persistent fantasies of success, power, attractiveness, intellectual superiority or ideal love

– Sense of superiority and specialness

– Wish to be admired

– Strong sense of entitlement

– Manipulates and exploits others

– Lack of empathy

– Believes others are envious of him/her and envy of others

– Arrogant and contemptuous attitudes and behaviours

The recent controversy over psychiatrists ‘diagnosing’ the current President of the USA, Donald Trump, with NPD led the American Psychiatric Association to issue a warning to its members to stop ‘psychoanalysing’ him, because it breached the organisation's code of ethics by offering a professional opinion without conducting an examination and being granted proper authorisation to make such a statement (Oquendo Reference Oquendo 2016 ), and it exemplifies some of the pitfalls of diagnosing personality disorders. The conceptual confusion in defining NPD may render this disorder particularly prone to being attributed to individuals, especially those in the public limelight, without taking a full history and examination, failing to confirm functional impairment or diagnosing on the basis of a single trait.

The diagnostic criteria for NPD in DSM-5, as noted above, are focused on characteristics of grandiosity and entitlement rather than more vulnerable manifestations of the disorder. It is now generally accepted that at least two subtypes or phenotypic presentations of pathological narcissism can be differentiated: grandiose or overt narcissism and vulnerable or covert narcissism (Cain Reference Cain, Pincus and Ansell 2008 ; Pincus Reference Pincus, Cain and Wright 2014 ). People with the former subtype may appear arrogant, pretentious, dominant, self-assured, exhibitionist or aggressive, whereas people with the latter may present as overly sensitive, insecure, defensive and anxious about an underlying sense of shame and inadequacy. These two opposing presentations have been well described in the psychoanalytic literature, exemplified by Rosenfeld's original description of ‘thick-skinned’ and ‘thin-skinned’ narcissism (Rosenfeld Reference Rosenfeld 1987 ), ideas elaborated by Bateman ( Reference Bateman 1998 ) and Britton ( Reference Britton 2003 ), who emphasise how the coexistence of thick- and thin-skinned narcissistic aspects in the same individual may be understood as the former defending against the latter, and raise some of the technical challenges of how to address these in treatment, as described later in this article.

These theories highlight how the narcissistic person's overt attitudes and behaviours may differ markedly from their inner subjective experience, where grandiosity may conceal an underlying sense of impotence, shame and inadequacy and, conversely, manifest shyness and reticence may shield a secret sense of importance. Moreover, healthy narcissistic functioning may coexist with pathological narcissism and vary according to context and interpersonal relationships. Nevertheless, both individuals with grandiose and those with vulnerable narcissism share a preoccupation with satisfying their own needs at the expense of the consideration of others: pathological narcissism is defined by a fragility in self-regulation, self-esteem and sense of agency, accompanied by self-protective reactivity and emotional dysregulation. Grandiose and self-serving behaviours may be understood as enhancing an underlying depleted sense of self and are part of a self-regulatory spectrum of narcissistic personality functioning (Ronningstam Reference Ronningstam and Gabbard 2014 ).

Confusion may arise, however, in the differential diagnosis of NPD from antisocial personality disorder and psychopathy. The overlap between conceptualisations of pathological narcissism and psychopathy is well-documented. In his seminal work on the characteristics of the psychopath, Cleckley ( Reference Cleckley 1941 ) includes several aspects of narcissism, such as a sense of entitlement, ego-centricity and lack of empathy, which are reflected in the Psychopathy Checklist – Revised (PCL-R; Hare Reference Hare 2003 ), the most commonly used risk-assessment instrument measuring psychopathy in forensic settings. Kernberg proposes that psychopathy is a malignant form of narcissism characterised by NPD, antisocial features, paranoid traits and sadism (Kernberg Reference Kernberg 1992 ). However, neither malignant narcissism nor psychopathy is recognised as a discrete diagnostic category in the DSM or ICD classifications of mental disorders. Features of psychopathy are subsumed within the broader DSM category of antisocial personality disorder, which is the most common personality disorder that is comorbid with NPD. Patients with NPD who also have features of antisocial personality disorder and psychopathy may present a higher risk to others and may need to be managed within forensic services.

Most of the epidemiological research on NPD has been conducted using clinical samples, and studies measuring the prevalence of NPD in the general population are lacking. Community studies of the prevalence of personality disorders have been hindered by their small sample sizes and their confinement to specific geographical areas such as individual cities, limiting statistical analysis of the sociodemographics of NPD. A systematic review of studies reporting the prevalence of NPD in adult non-clinical samples found seven studies that used structured or semi-structured interviews to assess for personality disorder: the overall mean prevalence of NPD was 1.2% and the range 0–6.2% (Dhawan Reference Dhawan, Kunik and Oldham 2010 ). The most recent and comprehensive of these studies is the Wave 2 National Epidemiologic Survey on Alcoholism and Related Conditions (NESARC). This was a large, nationally representative epidemiological survey of 34 093 civilians in the USA carried out between 2004 and 2005, which assessed alcohol and drug use, psychiatric disorders, and the risk factors associated with and the consequences of alcohol and drug use, by conducting face-to-face interviews (Hasin Reference Hasin and Grant 2015 ). This survey showed an overall prevalence of NPD of 6.2%, with rates higher for men (7.7%) than for women (4.8%). NPD was also significantly more common in Black men and women and Hispanic women, younger adults and people who were separated, divorced, widowed or never married. High rates of co-occurring substance use, mood, anxiety and other personality disorders were observed (Stinson Reference Stinson, Dawson and Goldstein 2008 ). The prevalence of NPD in the UK population is not known, as it has not been specifically measured in large-scale studies of the prevalence of mental disorders here, such as the British psychiatric morbidity surveys (Jenkins Reference Jenkins, Bebbington and Buhgra 2003 ).

NPD has a relatively low prevalence in most clinical samples of patients with mental or personality disorders (Zimmerman Reference Zimmerman, Rothschild and Chelminski 2005 ; Katerud Reference Katerud and Wilberg 2007 ). Depression and dysthymia are the most commonly found comorbid mental illnesses in NPD. Symptoms of NPD, in particular grandiosity and inflated self-esteem, may be seen in the manic phase of bipolar disorder, and it is not clear whether the comorbidity between the two disorders is a reflection of shared vulnerability or is just an overlap of diagnostic criteria. NPD is a relatively common comorbid disorder in drug and substance use disorders and has also been found to be comorbid with anxiety disorders, anorexia nervosa and post-traumatic stress disorder. People with NPD are at increased risk of suicide (Ronningstam Reference Ronningstam 1996 ). The DSM-5 personality disorders most frequently found to be comorbid with NPD are histrionic personality disorder and antisocial personality disorder (Widiger Reference Widiger, Trull, Widiger, Francis and Pincus 1998 ), which may pose difficulties in differential diagnosis. The overall relatively low prevalence rates of NPD reported in samples from both clinical settings and the general population may in part be due to the narrow concept identified by the DSM-5 diagnosis, which does not capture the more vulnerable aspects of pathological narcissism.

There is an extensive and rich literature regarding aetiological theories of narcissism, predominantly from psychoanalytic and psychodynamic perspectives, but more recently from social learning theory and from attachment research. As described above, these theories have been informed by clinical practice and treatment for narcissistic patients and it is only in the past 15 years or so that they have been put to empirical testing. Most of these recent studies have primarily focused on parental behaviour, and although there are differences in measures of narcissism and parenting style, ages of children studied and nationality of participants, all converge to support psychodynamic and learning theories in showing that dysfunctional parenting is significantly associated with the development of pathological narcissism in adulthood (for a comprehensive review of these studies see Horton Reference Horton, Campbell and Miller 2011 ). Interestingly, although studies suggest that parental indulgence is associated with both grandiose narcissism and vulnerable narcissism, parental coldness and emotional control of the child are more likely to be associated with vulnerable narcissism.

Emerging evidence that very early disturbances in the relationship between the child and primary caregiver may be linked to the development of narcissism arises from attachment research, in which studies have reported an association between both dismissing and preoccupied attachment styles as measured on the Adult Attachment Interview and pathological narcissism and NPD in adults (Rosenstein Reference Rosenstein and Horowitz 1996 ; Dickinson Reference Dickinson and Pincus 2003 ; Smolewska Reference Smolewska and Dion 2005 ; Otway Reference Otway and Vignoles 2006 ; Bakermans-Kranenburg Reference Bakermans-Kranenburg and van IJzendoorn 2009 ; Miller Reference Miller, Dir and Gentile 2010 ; Diamond Reference Diamond, Levy and Clarkin 2014 ; Fossati Reference Fossati, Feeney and Pincus 2014 ). These contradictory attachment patterns (i.e. dismissing and anxious/preoccupied) have been linked respectively to the mental states of grandiosity and vulnerability found in NPD (Cain Reference Cain, Pincus and Ansell 2008 ; Meyers Reference Meyers, Pilkonis, Campbell and Miller 2011 ).

Very few studies have looked at a genetic basis for NPD. One such, assessing cluster B personality disorders in 1386 Norwegian twin pairs between the ages of 19 and 35, estimated a heritability of 24% for NPD compared with 38% for antisocial personality disorder, 35% for borderline personality disorder and 31% for histrionic personality disorder (Torgersen Reference Torgersen, Czajkowski and Jacobson 2008 ). In another, 144 community participants belonging to 36 biological family groups completed the Narcissistic Personality Inventory and a measure of parenting style. Results indicated a significant father–daughter correlation for levels of narcissism, but close to zero correlations for other parent–offspring dyads. The authors cautiously interpreted this as evidence for a possible genetic basis, including X-chromosome involvement, for narcissistic personality traits, with parenting style contributing relatively little (Miles Reference Miles and Francis 2014 ).

Individuals with symptoms of NPD may present to primary care services with a variety of complaints, although the diagnosis is often missed at this stage. They seek treatment for various reasons, but a common theme is that their experience of life, and in particular of their relationships, does not live up to their elevated standards and expectations. They often have little insight that their difficulties may be due to problematic personality traits and instead externalise their problems, projecting them onto others. A sense of victimhood or entitlement is common, with the patient blaming others for treating them badly or criticising them for faults that they see in other people but deny in themselves. They may also present in crisis, describing difficulties with or complaints from family, friends or employers, or legal sanctions that they do not accept; or they may be referred to mental health services because of comorbid mental conditions, such as a depressive disorder, or suicidality. Other manifest difficulties include social isolation, sexual dysfunction, irritability and aggression, and an increasing reliance on drugs and/or alcohol to elevate mood. Some report feelings of emptiness, dysphoria and despair; in others, feelings of shame, humiliation and worthlessness may predominate, particularly in relation to events such as the break-up of a relationship or loss of their job.

The most common entry point for patients with NPD to psychological therapy services in the UK is through the Improving Access to Psychological Therapies (IAPT) programme, where again, the disorder may not be immediately recognised. If the diagnosis is made, patients often reject it as it challenges their sense of specialness and/or may accentuate feelings of low self-worth, shame and humiliation. Patients are rarely referred to secondary mental health services on account of a diagnosis of NPD, but they may present because of comorbid mental illness such as anxiety or depressive disorders.

People with NPD are often difficult to engage in treatment, which underscores the importance of gradually building a therapeutic alliance, with mutually agreed goals within a clearly outlined treatment frame in the initial stages of any treatment offered. If a therapeutic process can be initiated, frequent ruptures in the therapeutic relationship should be anticipated, often precipitated by the patient feeling criticised or unfairly treated by the clinician. The patient may also resent the perceived power or expertise of the clinician and reject any treatment offered. Alternatively, narcissistic individuals may wish to please the therapist and be their favourite patient; such individuals are often skilled at learning what is expected of them in therapy and may report improvement without evidence of any real therapeutic change.

As in some individuals with antisocial or histrionic personality disorder, feelings of shame and humiliation arising in relation to perceived slights and lack of respect from others may be a central conflict for people with NPD and may cause particular challenges within the therapeutic relationship. The offer of therapeutic help may in itself precipitate feelings of shame if the individual equates weakness and vulnerability with being a patient. Such feelings of vulnerability may be experienced as intolerable and may be defended against by projection, grandiosity and omnipotence within the relationship between patient and therapist, so that the latter is the one who feels shameful and inadequate. Such countertransferential responses in the therapist may be understood psychoanalytically as an unconscious communication from the patient to the therapist of the former's problem in receiving and using help, via the process of projective identification (Klein Reference Klein and Klein 1946 ) in which the therapist is made to feel feelings that the patient disowns. Returning to the myth of Narcissus and Echo, this illustrates the idea of how Narcissus thwarts a relationship by turning away from the desire for connection, leaving a rejected and vulnerable part of himself reflected in the character of Echo. Similarly, in trying to make a connection with a narcissistic patient, the professional may need to unconsciously bear the echo of the patient's narcissistic psychopathology and tolerate holding the rejected and vulnerable part of the patient's self.

These treatment challenges highlight the complex countertransferential responses that may be provoked in clinicians, such as frustration, anger or therapeutic nihilism, or, on the contrary, feelings of specialness and therapeutic expertise. This underscores the importance of regular clinical supervision, reflective practice, case discussion groups or Balint groups, regardless of treatment modality, in which the clinician's feelings can be safely explored to gain insight into the patient's psychopathology and interpersonal difficulties and the way they affect the therapeutic relationship. It should be recognised, however, that feelings of shame and resentment in therapists and other professionals in contact with narcissistic patients may make it particularly difficult for them to seek or effectively use supervision, with the risk that unhelpful and even punitive countertransferential responses by clinicians, for example refusing access to treatment, may go unchecked ( Box 2 ).

BOX 2 Case vignette: entitlement and grandiosity

Marco, a middle-aged man, was referred to mental health services following an overdose taken in the context of the break-up of a relationship. He was assessed by a female higher trainee in general adult psychiatry, who recommended that he be referred to the psychological therapies service for an assessment for dialectical behaviour therapy (DBT). He reported previously receiving several years of intensive psychotherapy in his home country with ‘a well-known analyst’. Following this assessment, he complained that the psychiatrist who had seen him was clearly too young and inexperienced to understand the complexity of his difficulties and demanded to be seen by a more senior clinician. The consultant psychiatrist, an older man, agreed to review him. He noted that Marco probably fulfilled criteria for narcissistic personality disorder, but that it would be counterproductive to discuss this diagnosis with him. Instead, he acknowledged Marco's concerns and explained that, although the female psychiatrist was clearly younger than himself and Marco, nevertheless she was well trained and achieved as good results as any other clinician in the service. Moreover, he confirmed that DBT might be a suitable therapy at this point, as although it was time-limited, it would be more focused, particularly on destructive behaviours such as self-harm, and would give Marco skills to better manage his impulses and emotions, especially in the context of his relationships. He suggested that DBT could build on what Marco had achieved in his previous therapy. Marco subsequently engaged in a DBT programme and, although he frequently complained that the treatment was much more ‘superficial’ than his previous therapy, he made some gains, particularly in controlling his self-harm and being able to acknowledge chronic feelings of low self-worth.

Box 3 lists some common challenges in the treatment of NPD. Please note all case vignettes in this article are fictitious.

BOX 3 Case vignette: countertransference

Andrew had recently come to the UK from the USA, where he had sought treatment for depression and had been briefly admitted as an in-patient because of concerns regarding his suicide risk. However, following several incidents in which he became confrontational with other patients and staff on the ward when his demands were not met immediately, he had been discharged with the explanation that he had narcissistic personality disorder and was clearly unable to benefit at the time from treatment. Still feeling wounded and angry on arrival in the UK, he again started experiencing suicidal thoughts and was referred for a psychiatric assessment. He was initially seen by a junior trainee in psychiatry, who was unable to complete the assessment as he found it difficult to interrupt the patient's lengthy accounts of being ‘disrespected’ by others, including members of the psychiatric profession. Believing that a doctor's professional code of conduct meant that he should not feel negative emotions towards patients, the trainee suppressed his anger but was left feeling ashamed that he had not been able to properly assess the patient. Fearing that his supervising consultant would reprimand him for this, he feigned illness on the day of their next scheduled clinical supervision. However, he eventually felt able to talk about this situation in the Balint group for trainee psychiatrists that he attended, where the therapist enabled him to understand his countertransferential reaction to the patient as a projection of the patient's feelings of shame and rejection resonating with the trainee's own doubts regarding his competencies and skills as a psychiatrist in training.

There is no evidence that any specific psychopharmacological treatment is effective for NPD, although comorbid mental illnesses such as anxiety, depression and bipolar disorder should be treated in their own right. People with NPD may report being particularly sensitive to the side-effects of medication, particularly those that affect their sexual function or intellectual capacity; they may also resent the idea that they might be dependent on pharmacological interventions. These factors may reduce their adherence to treatment.

The mainstay of treatment for NPD is psychological therapy. A number of specific treatment modalities and strategies have been developed and advocated for people with pathological narcissism or NPD, but none have been robustly tested for efficacy, and although there is emerging empirical evidence for their effectiveness, no one modality has been proved superior to any other. However, across these differing approaches, common strategies and techniques have been found to be useful, such as the necessity of building a positive therapeutic alliance ( Box 4 ).

BOX 4 Challenges in the treatment of narcissistic personality disorder

• Premature termination of treatment or sudden drop-out

• Sensitivity to developmental life changes (e.g. marriage, childbirth, aging) and sudden life events that can disrupt the treatment alliance

• Rejection of the diagnosis, especially features of grandiosity, entitlement and lack of empathy

• Sensitivity to feeling blamed, criticised and unfairly treated, including by the therapist

• Poor affect tolerance, especially of feelings of shame, humiliation and vulnerability

• Wish to please/impress the therapist or imitation of their views without evidence of therapeutic change

• Seeking therapy after several failed previous treatments

• Suicidal ideation and behaviour

• Secondary gain from symptoms

• Aggressive, antisocial or psychopathic features, which are associated with poorer prognosis

• Negative countertransferential feelings in the treating clinician, which may lead to unhelpful or punitive responses such as excluding the patient from treatment

Psychotherapeutic treatments of NPD have been developed from within two main traditions: the psychoanalytic/psychodynamic and the cognitive–behavioural. These two approaches differ by being based on distinct theoretical models, paradigms and frameworks, but they share certain techniques and therapeutic interventions. There is increasing support for a more integrated approach to the treatment of personality disorders, including NPD (Livesley Reference Livesley 2012 ), with the recognition that different modalities and techniques can be used synergistically and in a step-wise fashion for the different presentations and developmental stages of the disorders.

In most of the psychotherapeutic modalities described below, the treatment is one-to-one therapy; however, group therapy may be effective in challenging difficulties related to shame, dependency, self-sufficiency, and contempt for and envy of others, although highly narcissistic individuals may dominate or disrupt groups and compete with the therapist to be group leader ( Box 5 ).

BOX 5 Top tips for assessing and managing individuals with narcissistic personality disorder

• Anticipate being treated as an audience to the patient's performance

• Expect to be drawn into lengthy accounts of the patient's life

• In interviewing the patient, agree at the start how and why you will interrupt

• Anticipate negative responses to perceived criticism – any comment that may be interpreted as disrespectful or generates a feeling of shame or humiliation

• Avoid directly challenging a patient, even when they express very negative attitudes

• Be empathic without colluding with what the patient says

• Reflect on negative countertransference reactions rather than revealing these to the patient

Psychodynamic approaches

Psychodynamic psychotherapy is grounded in psychoanalytic principles, but it is based on a broader theoretical framework capturing relational, interpersonal, intersubjective and embodied experiences of both the social world and the internal world.

Transference-focused psychotherapy

The most prominent psychodynamic psychotherapy that has been specifically designed for the treatment of NPD is transference-focused psychotherapy, developed by Kernberg and his collaborators in the USA (Clarkin Reference Clarkin, Yeomans and Kernberg 2006 ). Originally developed for the treatment of borderline personality disorder, transference-focused psychotherapy is based on the principles of psychoanalytic object relations theory and its technique is aimed at the active exploration of the patient's aggression, envy, grandiosity and defensiveness. Interpretations are targeted towards uncovering the negative transference, challenging the patient's pathological grandiose defences, and exploring their sensitivity to shame and humiliation; the therapist's countertransference is used as a tool to understand the patient's projection of unacceptable aspects of themselves. Transference-focused psychotherapy is a manualised one-to-one therapy delivered two or three times a week, and it has been shown in randomised controlled trials to improve symptomatic and reflective functioning in borderline personality disorder (Clarkin Reference Clarkin, Levy and Lenzwenger 2007 ). For more narcissistic patients, a less interpretative and more supportive technique is used. There has been growing interest in transference-focused psychotherapy in the UK over the past decade, and it is available in some National Health Service (NHS) psychological therapy services.

Mentalisation-based treatment

In the UK, mentalisation-based treatment, also originally developed for the treatment of borderline personality disorder, has been used in the treatment of other mental disorders (Bateman Reference Bateman and Fonagy 2012 ). This group and individual therapy is based on attachment theory and it integrates psychodynamic, cognitive and relational components. It focuses on enhancing mentalisation – the ability to reflect on one's own and others’ states of mind and link these to actions and behaviour Although mentalisation-based treatment has not been systematically studied in relation to NPD, there are a few reports in the literature of mentalisation-based treatment programmes specifically designed to treat the disorder (Cherrier Reference Cherrier 2013 ; Lee Reference Lee, Mach and Grove 2013 ) and of the use of mentalisation-based treatment or mentalisation techniques with patients with narcissistic traits (Seligman Reference Seligman 2007 ; Rossouw Reference Rossouw 2015 ). Both transference-focused psychotherapy and mentalisation-based treatment draw from attachment research in their conceptualisations of the psychopathology of NPD.

Cognitive–behavioural approaches

Several specific empirically based therapeutic modalities developed for the treatment of personality disorder from within a cognitive–behavioural framework have been modified for patients with narcissistic difficulties or disorder. These include schema-focused therapy, dialectical behaviour therapy and metacognitive interpersonal therapy. Therapists and researchers have adapted Beck's cognitive therapy model (Beck Reference Beck and Freeman 1990 ) to treat narcissistic thoughts and behaviours. Cognitive techniques such as cognitive reframing, problem-solving and altering dysfunctional thoughts, coupled with behavioural modification techniques such as impulse control, maintaining eye contact and reducing grandiosity, have been demonstrated in narcissistic patients to strengthen the therapeutic alliance and increase adherence to therapy and therapeutic goals (Cukrowicz Reference Cukrowicz, Poindexter, Joiner, Campbell and Miller 2011 ).

Schema-focused therapy

Schema-focused therapy is an integrative psychotherapy that expands strategies from traditional cognitive–behavioural therapy, but also systematically incorporates elements from object relations, psychodynamic and gestalt therapeutic models. Originally developed by Jeffrey Young and colleagues in The Netherlands (Young Reference Young, Klosko and Weishaar 2003 ), it is increasingly used in the UK and other countries to treat borderline personality disorder, and there is some evidence from randomised controlled trials for its efficacy in the treatment of that disorder (Giesson-Bloo Reference Giesson-Bloo, van Dyck and Spinhoven 2006 ). To date, no clinical trials of schema-focused therapy have been conducted for NPD, but clinical reports suggest that it may be effective for the disorder. Schema-focused therapy focuses on challenging early maladaptive schemas regarding relationships to self and others and on promoting a healthier ‘adult mode’ of functioning. The therapist uses a process of ‘re-parenting’, encouraging the patient to better regulate narcissistic fluctuations in emotional reactivity and to develop empathy for and achieve emotional intimacy with others.

Dialectical behaviour therapy

Dialectical behaviour therapy is a manualised treatment developed by Marsha Linehan ( Reference Linehan 1993 ) in the USA, again originally for borderline personality disorder, for which there is evidence of efficacy in randomised controlled trials. It combines individual and group therapy sessions and incorporates cognitive–behavioural principles with acceptance and mindfulness-based skills originating in Buddhist philosophy. Group skills-training sessions are used to promote mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness. It has been used with some patients with symptoms of NPD (Reed-Knight Reference Reed-Knight, Fischer, Campbell and Miller 2011 ), with whom validation is a key technique to reduce the feelings of shame and self-criticism common in the disorder ( Box 6 ).

BOX 6 Case vignette: a disruption of group dynamics

Laura, a socially isolated woman with prominent narcissistic pathology, attended a mentalisation-based treatment group for patients with a range of personality disorders. When other group members spoke, she would frequently lean back in her chair, look bored, close her eyes and not contribute to the ensuing discussion unless it directly related to herself. At other times she would dominate the group discussion, frequently interrupt the therapist and give advice to others about how they should change their behaviour. Another group member eventually complained that Laura was clearly disinterested in what they were saying and that her behaviour was rude and disrespectful. The therapist said that he had noticed that Laura seemed to zone out when others talked and he could see that others might interpret this as rudeness, but he wondered how Laura felt during these moments and whether she was even aware of her behaviour. Laura said she wasn't sure that she was bored – she just automatically ‘switched off’ sometimes, especially when people spoke too fast or loudly and went ‘on and on about their problems’. What gradually became clearer and could be talked about more openly over several sessions was why Laura retreated and appeared to be dismissive and contemptuous when the emotional intensity of the interactions between group members became too heated. She became able to identify this withdrawal as a way of managing fleeting feelings of anxiety, inadequacy and self-consciousness when others spoke about their relationships: she had been coping only by telling herself that she was not as disturbed as the other group members and that it was a waste of time being in the group.

Meta-cognitive interpersonal therapy

Meta-cognitive interpersonal therapy for NPD is a manualised step-by-step treatment developed in Italy by Giancarlo Dimaggio and colleagues (Dimaggio Reference Dimaggio and Attinà 2012 ) and particularly focusing on perfectionism. It is aimed at dismantling narcissistic processes, with shared understanding of the patient's problems in their autobiographical context, progressing to recognition of maladaptive schemas and interpersonal functioning, and finally to promoting change through identification of grandiosity, distancing from old behaviour, reality- and perspective-taking and building more healthy schemas.

Historically, research activity into the nature and treatment of problematic narcissistic personality traits, pathological narcissism and NPD has been much greater in the USA and, to some degree, in other European countries, particularly Italy, than in the UK. Similarly, a formal diagnosis of NPD is less frequently made by psychiatrists in the UK, and the specific treatment modalities adapted for this disorder are generally less available here than in the USA. This apparent lack of interest in the disorder in the UK may in part be because ICD-10 (World Health Organization 1992 ), which does not list NPD as a recognised specific personality disorder, is used as the official diagnostic classification system for mental disorders in this country, rather than DSM-5.

Nevertheless, regardless of whether a formal DSM diagnosis of NPD is made, psychiatrists should be alert to the presence of narcissistic pathology in their patients, as it may significantly influence their management and treatment within mental health services. Moreover, personality disorder services are increasingly offering a range of evidence-based psychological interventions, and although for the most part these are not specifically targeted at people with NPD, the adaptations and innovations in therapeutic technique that are being developed by specialists in the field should be of interest to any clinician involved in treating this difficult patient population.

Work with these individuals highlights the fine balance between healthy and pathological narcissism, the problems of desire and dependency, and the challenges in accepting human limitation, vulnerability and need that exist in all of us. All clinicians should strive for compassion towards patients at risk of re-enacting the story of Narcissus, who turned away from life and love towards the death of Echo and himself in the ultimate narcissistic act.

Select the single best option for each question stem

a Freud was the first to conceptualise narcissism as a clinical entity

b Freud, Rank and Winnicott all conceptualised narcissism as a dimensional psychological state that ranged from normal to pathological

c Kernberg emphasises conflict and aggression in the development of pathological narcissism

d social–personality psychology conceptualises narcissism as a maladaptive personality trait

e Millon's social learning perspective proposes that pathological narcissism results from early parental neglect.

a is weighted towards the vulnerable aspects of the disorder

b is modelled on a dimensional/categorical hybrid

c is usually welcomed by the patient in providing a legitimate diagnosis of their difficulties

d is unchanged from DSM-IV

e is best measured by the Narcissistic Personality Inventory.

a studies consistently report a prevalence in non-clinical samples of 1–3%

b the most frequent DSM-5 personality disorders comorbid with NPD are borderline personality disorder and histrionic personality disorder

c NPD is more common in older White men

d comorbidity between bipolar affective disorder and NPD suggests that both disorders may share underlying aetiological factors

e empirical studies have reported that the prevalence of NPD is greater in the USA than in the UK.

a genetic factors are unlikely to have an influence in the development of NPD

b patients with NPD whose presentation is characterised by prominent grandiosity are more likely to have dismissing attachment patterns as measured on the Adult Attachment Interview

c studies show that parental coldness is consistently associated with both grandiose narcissism and vulnerable narcissism

d Kernberg suggests that a failure of parental empathy is a main contributor to the development of NPD

e sibling rivalry is likely to be a contributory factor.

a individual therapy is the treatment of choice

b cognitive behavioural therapy has been shown to have superior efficacy to other modalities

c the patient may simulate therapeutic progress

d the patient is best treated by an experienced clinician

e patients with more prominent symptoms of low self-worth are less likely to drop out of therapy.

MCQ answers

1 c 2 d 3 d 4 b 5 c

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• Published: 03 August 2021

Narcissistic personality traits and prefrontal brain structure

• Igor Nenadić 1 , 2 , 3 ,
• Carsten Lorenz 3 &
• Christian Gaser 3 , 4  

Scientific Reports volume  11 , Article number:  15707 ( 2021 ) Cite this article

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• Brain imaging
• Human behaviour
• Social neuroscience

Narcissistic traits have been linked to structural and functional brain networks, including the insular cortex, however, with inconsistent findings. In this study, we tested the hypothesis that subclinical narcissism is associated with variations in regional brain volumes in insular and prefrontal areas. We studied 103 clinically healthy subjects, who were assessed for narcissistic traits using the Narcissistic Personality Inventory (NPI, 40-item version) and received high-resolution structural magnetic resonance imaging. Voxel-based morphometry was used to analyse MRI scans and multiple regression models were used for statistical analysis, with threshold-free cluster enhancement (TFCE). We found significant ( p  < 0.05, family-wise error FWE corrected) positive correlations of NPI scores with grey matter in multiple prefrontal cortical areas (including the medial and ventromedial, anterior/rostral dorsolateral prefrontal and orbitofrontal cortices, subgenual and mid-anterior cingulate cortices, insula, and bilateral caudate nuclei). We did not observe reliable links to particular facets of NPI-narcissism. Our findings provide novel evidence for an association of narcissistic traits with variations in prefrontal and insular brain structure, which also overlap with previous functional studies of narcissism-related phenotypes including self-enhancement and social dominance. However, further studies are needed to clarify differential associations to entitlement vs. vulnerable facets of narcissism.

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Narcissism refers to a set of personality traits incorporating cognitive, emotional, and behavioural features, which are commonly conceptualised around facets of grandiosity, entitlement, and vulnerability 1 , 2 , 3 . Current conceptualisations of narcissism therefore consider a bipolarity of grandiose vs. vulnerable narcissism or multipolarity of major facets, often evolving around deficits in maintaining functional levels of self-esteem, with such traits being common in the general population and not uniformly linked to dysfunction or distress 2 .

Narcissistic traits have been studied both in social or personality psychology as well as clinical contexts, especially with reference to narcissistic personality disorder (NaPD) 4 , 5 , 6 . While the case has been made that clinical research on narcissistic personality disorder might benefit from data obtained in non-clinical studies of narcissistic traits 7 , the relation between the conceptualisations in these two different lines of research is by no means clear and a matter of ongoing debates and research 3 , 6 , 8 . In the subclinical range, narcissistic traits can be associated with positive effects in initial group formation and leadership, but often lead to adverse interactional outcomes over time 9 , 10 .

Psychometric characterisation of the narcissistic phenotype in general population cohorts has relied on well-established and validated questionnaires, in particular the Narcissistic Personality Inventory (NPI) by Raskin and Hall 11 , which considers aspects of grandiosity, as well as leadership and entitlement 12 , 13 , 14 , 15 , 16 . Hence, while alternative more recent scales have become available 16 , 17 , 18 , the NPI still remains a widely used instrument 19 , 20 with a large database of studies 21 , 22 .

Given the relevance of narcissism in both clinical and non-clinical research fields, there is an astonishing paucity of neuroscience research relating narcissistic traits or behaviours to either brain function or structure. A pioneering explorative functional magnetic resonance imaging (fMRI) study comparing 11 high-narcissistic vs. 11 low-narcissistic subjects using an empathy paradigm implied decreased deactivation in the right anterior insula in the high-narcissism group 23 , an area implicated in cognitive empathy 24 , 25 , 26 , which can be considered a main factor in developing prosocial behaviours 27 , 28 . Further functional studies have found correlations of narcissistic traits in clinically healthy subjects in anterior insula and dorsal anterior cingulate and subgenual cingulate cortices during tasks involving social rejection 29 , as well as elevated dorsal anterior cingulate cortex (dACC) response to social rejection stimuli 30 and self-related visual stimulus processing 31 . In an EEG study, feed-back related negativity in midline frontal areas in an EEG study did not differ between low vs high narcissistic subjects, but a difference in centro-parietal P3 emerged 32 . Together with studies implicating impaired structural white matter connectivity in frontostriatal tracts 33 , this gives rise to (anterior) insula and prefrontal (esp. dACC) involvement in narcissistic behaviours.

In contrast to these cues from functional imaging studies, there is no clear evidence on the brain structural underpinnings, esp. for grey matter. One previous study using cortical thickness measurements reported a negative correlation of PNI (pathological narcissism inventory) scores with right dorsolateral and inferior prefrontal thickness, and cortical volumes in the left medial prefrontal and right dorsolateral prefrontal cortices 34 , while another showed an interaction of gender and NPI scores in the right superior parietal cortex using voxel-based morphometry 35 .

The present study was conducted to test the association of brain structure and narcissistic traits in a non-clinical cohort. In particular, we tested the hypothesis that subclinical narcissistic traits (assessed with the NPI) would be correlated with prefrontal brain structures (as implicated in functional studies and one of the preceding cortical mapping studies) as well as the (anterior) insula. We chose a whole-brain voxel-wise analysis for spatial resolution to distinguish between different areas of the orbital, medial, and lateral prefrontal cortices.

Study cohort and phenotyping

For this study, we analysed data from a total of 103 psychiatrically healthy subjects (53 female, 50 male) recruited from the local community. All participants gave written informed consent to study participation as part of a study protocol approved by the local ethic committee of the Medical School of Friedrich-Schiller-University of Jena, in accordance with the Declaration of Helsinki in its current version. Inclusion criteria were age 18–65 years and ability to provide informed consent, while exclusion criteria were any concurrent or previous psychiatric disorder (including current substance dependence) central nervous neurological disorders (including traumatic brain injury/loss of consciousness), or learning disability/IQ lower than 80, as well as intake of psychotropic medication.

Subjects were screened for absence of exclusion criteria, in particular any previous treatment for psychiatric disorders. IQ was estimated using the MWT-B (Mehrfachwortschatztest B; 36 , 37 ), and while IQ scores lower 70 would be considered suggestive of a learning disability, we defined an exclusion threshold of 80 to take into account imprecisions and potential overestimations of this screening test (ultimately, however, none of our recruited subjects was excluded as the minimum detected IQ in this sample was 88). Following screening and formal inclusion, subjects underwent MRI scanning and phenotyping for narcissistic traits.

We used the narcissistic personality inventory NPI 11 , applying the full 40-item validated German version 38 , to characterise our sample for narcissistic traits. The NPI has been used in a large number of studies 20 , 39 , including non-clinical and clinical samples, as well as several of the functional imaging studies cited above. While validity studies of the NPI by Raskin and Terry suggested seven components defined as authority, exhibitionism, superiority, vanity, exploitativeness, entitlement, and self-sufficiency 40 , there have been alternative accounts of four factors labelled exploitativeness/entitlement, leadership/authority, superiority/arrogance, self-absorption/self-admiration 15 , and more recently of two or three factors assigned ‘power’, ‘exhibitionism’, and ‘special person’ 41 . In particular, Ackerman and colleagues in a recent re-appraisal of the NPI including analyses of large college student samples 12 , advocated a three-factor model (with facets: leadership/authority, grandiose exhibitionism, and entitlement/exploitativeness). Based on findings of the validation study and factorial analysis of the German NPI translation 38 , we calculated additional seven NPI subscales designated (sample items in brackets refer to the original NPI text in English): authority (8 items, e.g.: “I am a born leader”), entitlement (6 items, e.g.; “I insist upon the respect that is due me.”), exhibitionism (7 items, e.g.: “Modesty doesn’t become me.”), exploitativeness (6 items, e.g.: “I can make anybody believe anything I want them to”), self-sufficiency (6 items, e.g.: “I rarely depend on anyone else to get things done.”), superiority (5 items, e.g.: “I think I am a special person.”), vanity (3 items, e.g.: “I like to look at myself in the mirror”).

Demographic and psychometric data of the sample are summarised in Table 1 .

Magnetic resonance image (MRI) acquisition

MRI scanning was done on a 3 Tesla Siemens Tim Trio system (Siemens, Erlangen, Germany) using a T1-weighted high-resolution MPRAGE sequence (magnetisation-prepared rapid gradient echo) with a standard quadrature head coil (scanning parameters: TR 2300 ms, TE 3.03 ms, flip angle α 9°, in-plane field-of-view 256 mm) acquiring 192 contiguous sagittal slices covering the whole brain. Scanning duration was 5:21 min. All scans were visually inspected after scanning for gross artefacts (e.g. movement, ghosting), and all scans passed this initial step of quality assurance.

Voxel-based morphometry

We used a voxel-based morphometry (VBM) approach to analyse T1 scans, using Statistical Parametric Mapping (SPM) software (Wellcome Institute of Imaging Neuroscience, Institute of Neurology, London, UK) running on Matlab (Mathworks, Natik, MA, USA) and the VBM8 toolbox, r435 (C. Gaser, Jena University Hospital; http://www.dbm.neuro.uni-jena.de/vbm/vbm8 ), as in two previous studies of personality traits and narcissistic personality disorder, respectively 42 , 43 . Our processing pipeline have been described previously (e.g. 43 ), including augmentation of segmentation through accounting for partial volume effects 44 , adaptive maximum a posteriori estimation 45 , and hidden Markov Random Field models 46 . All scans passed the automated quality assurance protocol in VBM8. After segmentation of grey matter maps, we applied an internal grey matter threshold of 0.2, in order to eliminate potential artefacts at ambiguous grey matter borders; this threshold is more conservative than the often used 0.1 GM threshold. Anatomical labelling was available with the AAL atlas 47 .

Statistical analysis

For all VBM statistical analysis, we used threshold-free cluster enhancement (TFCE), an approach introduced to increase sensitivity of voxel-based analyses 48 , 49 , applying 5000 permutations (Smith method).

First, we tested our main hypothesis of brain structural associations with NPI scores using a general linear model (GLM) in SPM with NPI total score as regressor and age and sex as nuisance variables (in order to remove age and sex related effects). Based on TFCE, we then used a p  = 0.05 family-wise error (FWE) correction to correct for multiple comparisons across whole-brain GM voxels, testing for both positive and negative correlations. NPI skewness of 0.411 was in an acceptable range for this statistical approach.

Second, we followed up our main analysis by testing the hypothesis of sex interactions, i.e. that correlation slopes might differ significantly between female and male study participants. For this purpose, we set up a new GLM, again using age as a regressor, to reveal areas in which female subjects would show a higher/steeper increase over males and vice versa. This analysis aimed at replicating the previous finding 35 of sexually dimorphic associations for the parietal cortex in a VBM study (with unclear main effects of NPI total scores).

The exploratory nature of this analysis acknowledges limited statistical power in these (smaller) subgroups of the study cohort, as well as interaction effects in VBM often being more difficult to detect given lack of sensitivity even in decent sized samples.

Third, we performed exploratory analyses testing for potential associations of the seven NPI subscales with brain structure, defining separate GLMs, each including the respective NPI subscale, as well as age and sex as nuisance variables.

Associations of NPI total score with brain structure

In our main analysis, we found significant ( p  < 0.05, FWE-corrected, TFCE) positive correlations NPI total scores with regional brain grey matter volume in four clusters including bilateral medial, orbital, and dorsolateral prefrontal as well as left insular cortices (see Figs.  1 and 2 ).

Voxel-based morphometry (VBM) analysis showing positive correlations of narcissistic personality inventory (NPI) total score with grey matter (TFCE analysis, p  < 0.05 FWE corrected, axial sections with z levels given beneath each section) (Image created using the VBM8 toolbox, version r435; C. Gaser, Structural Brain Mapping Group, Jena University Hospital, Jena, Germany; http://www.dbm.neuro.uni-jena.de/vbm/vbm8 ).

Voxel-based morphometry (VBM) analysis showing positive correlations of narcissistic personality inventory (NPI) total score with grey matter (TFCE analysis, p  < 0.05 FWE corrected, coronal sections with y levels given beneath each section) (Image created using the VBM8 toolbox, version r435; C. Gaser, Structural Brain Mapping Group, Jena University Hospital, Jena, Germany; http://www.dbm.neuro.uni-jena.de/vbm/vbm8 ).

Of the four significant clusters, the first cluster spanned a large confluence of regions mostly covering the prefrontal areas (cluster size k = 15,419, maximum intensity voxel at MNI space co-ordinates 10; 39; − 14 with p FWE-corr  = 0.005, with additional local maxima at 10; 47; − 20 and − 21; 24; 6 – both at p FWE-corr  = 0.006).

Additional clusters were k = 1377 voxels (maximum intensity voxel at − 12; 18; 48 with p FWE-corr  = 0.035; additional local maxima − 9; − 15; 60 with p FWE-corr  = 0.036 and − 3; − 4; 52 with p FWE-corr  = 0.037), and smaller clusters with k = 178 voxels (maximum intensity voxel at − 30; 9; 40 with p FWE-corr  = 0.045; additional local maxima 32;8;49 with p FWE-corr  = 0.047 and − 30; 11; 57 with p FWE-corr  = 0.047) and k = 102 voxels (maximum intensity voxel at − 44; 27; 7 with p FWE-corr  = 0.047), respectively, with clusters extending towards bilateral caudate nuclei.

Interaction effects with NPI total scores

We did not identify a significant interaction effect of sex and NPI total scores on brain structure at corrected thresholds ( p  < 0.05, FWE-corrected, TFCE) apart from one single voxel in the right lateral prefrontal cortex (k = 1; 58; 22; 3, p FWE-corr  = 0.05) with higher correlation slopes in women. In particular, we did not identify any sex-by-NPI interaction in the superior parietal cortex, as implicated in a previous study 35 .

In further exploratory analysis at uncorrected threshold levels ( p  < 0.001, uncorr.), women showed steeper positive correlations with NPI total scores than men in two right dorsolateral prefrontal clusters (k = 930; maximum intensity voxel 58; 22; 3; and k = 233; 36;26;28) and one in the right posterior parietal/occipital cortex (k = 116; 30; − 81; 40) and one single voxel at 8; − 25; 73. There were no inverse effects (i.e. steeper slopes in men compared to women) even at p  < 0.001 uncorrected thresholds.

Comparison of psychometric data between female and male participants did not show significant group-level differences, apart from one single scale with male subjects scoring higher on the NPI subscale entitlement (T-test: T = 2.898, p  = 0.005; assuming unequal variances based on Levene-test F = 11.154, p  = 0.001), and trend-level findings for higher values of total NPI score in male subjects (T-test: T = 1.749, p  = 0.083; assuming equal variance based on Levene-text F = 0.19, p  = 0.664), and higher values for NPI subscale authority in male subjects (T-test: T = 1.956, p  = 0.053; assuming unequal variances based on Levene-test F = 4.216, p  = 0.043).

Exploratory analysis of brain structure and NPI subscales

Exploratory analysis of the seven NPI subscales (authority, entitlement, exhibitionism, exploitativeness, self-sufficiency, superiority, vanity) revealed only small minor clusters in the following associations (only those with k > 15 reported): (a) for exhibitionism a positive correlation with two clusters in the left parietal lobe (k = 124; maximum at – 36; − 40; 52 with p FWE-corr  = 0.047) and right medial parietal/cingulate cortex (k = 17; maximum at 12; − 28; 33 with p FWE-corr  = 0.048), (b) for self-sufficiency a positive correlation with a cluster in the left medial prefrontal cortex (k = 84; maximum at – 10; 12; − 11 with p FWE-corr  = 0.048), (c) for superiority a positive correlation with a left anterior/rostral prefrontal cluster (k = 308; maximum at − 21; 56; 21 with p FWE-corr  = 0.032). However, we did not identify any other significant association on the brain structural level at p FWE-corr  < 0.05 levels. While this exploratory analysis initially used uncorrected p  < 0.001 thresholds, it is noteworthy that none of the above clusters would survive Bonferroni adjustment for multiple comparisons (across multiple GLMs).

The present study set out to test the hypothesis that subclinical narcissistic traits in a nonclinical population would be associated with brain structural variation of grey matter, esp. in prefrontal systems. And indeed, our findings provide evidence of a correlation of prefrontal cortical grey matter with NPI narcissism. Our interpretation of results is directed at the three main aspects of the study: first, the implication of insular and prefrontal cortical regions (including orbitofrontal, ventromedial/medial prefrontal, and dorsolateral prefrontal areas) towards a neurobiological model of narcissistic traits; second, the relation of our findings to the (limited) imaging studies in clinical narcissistic personality disorder (NaPD); and thirdly, an overlap of our findings with studies of related behavioural traits, such as social dominance or self-enhancement, which map to some of the identified regions.

Our findings extend the previous structural association studies of narcissism (measured with the PNI) and reduced right dorsolateral prefrontal thickness 34 by showing a (positive) correlation with a more widespread network of prefrontal areas including the medial/ventromedial and orbitofrontal cortices, subgenual anterior cingular as well as insular cortices. It is therefore the first to suggest multiple widespread prefrontal networks to be involved in the narcissistic phenotype. This is of relevance, esp. given a previous VBM study failing to demonstrate such an association 35 . This seems plausible, also given the multiple facets of narcissism on the phenotype level 1 , 50 , which do not make convergence on a single neuroanatomical region/network plausible. In fact, the insular finding potentially links our finding to both studies of cognitive empathy 27 , 51 , 52 as well as to studies in patients with clinical narcissistic personality disorder 52 . However, the latter study, similar to another pilot study in NaPD 42 , only had small sample sizes, and rather hinted to a lateral prefrontal deficit. It is worthwhile noting that, unlike the clinical studies, our findings showed a positive , rather than negative, correlation of the narcissistic phenotype with brain volumes. It is interesting to note that comparable VBM studies of nonclinical population assessing subclinical phenotypes, for example irritability/hostility 53 or impulsivity 54 have shown such positive correlations and it has been suggested that this might be due to a non-linear association across a broader continuum (from nonclinical to pathology), of which only a small proportion would be assessed in a nonclinical study; hence, if narcissism, like irritability or hostility would show an inverted-U-shape relation across the whole nonclinical-to-clinical spectrum, a study in the lower to mid nonclinical range might show positive correlations (see, e.g. 53 ). An additional interpretation might be that some aspects of narcissistic traits in a low expression, might be beneficial or even desirable in a particular (e.g. competitive) social context, but our lack of relevant social or other personality data in this sample does not allow for further testing in this particular cohort.

In comparing our findings to the literature, we also need to consider differences across narcissism inventories: in contrast to the NPI, the PNI focuses more on pathological narcissism, with a more thorough focus on vulnerable facets, which might be more closely associated with clinically relevant phenotypes (for discussion, see 3 , 8 , 55 ).

The discrepancies to the two previous nonclinical association studies using the PNI 34 and NPI 35 , respectively, might additionally be explained by data analysis methodology as well as culturally different expressions (e.g., see 56 ).

While our study only assessed brain structure, there are several links to functional imaging studies pertinent to aspects of the narcissistic phenotype, which link our findings to prefrontal and insular networks to the expression of relevant behaviours. One of these is social rejection, which has been related to networks including the anterior insula, dorsal ACC and subgenual ACC 29 —part of which also featured prominently in our findings. Similarly, a recent study on cognitive emotion regulation training demonstrated that vmPFC activity exerts a modulated emotional response in regulating emotions to aversive images 57 , which connects our study to previous hypotheses of deficient emotion regulation in narcissism and prefrontal brain networks. The mPFC, also identified in our study, has previously been linked to self-enhancement in a series of brain stimulation studies 58 , 59 , 60 .

Given the relative paucity of imaging studies of narcissistic traits in the narrow sense, we should like to point out that several previous studies have linked medial PFC structure and activity to social functions, especially pertaining to social dominance and self-enhancement. The “dominance behavioral system”, which has been linked to narcissistic and manic temperament phenotypes 61 , 62 provides such a framework. In fact, at least two recent fMRI studies of social dominance and hierarchies show brain activation foci in location similar to findings of our study: one showed social hierarchy processing in an anterior dorsolateral prefrontal cluster, slightly dorsal in localisation to our anterior prefrontal clusters 63 , while another showed modulation of dominance and subordination to a medial prefrontal/bilateral caudate network 64 . While the latter in particular are consistent with more general conceptualisations of biological dominance, it should be pointed out that this inference is indirect at best, and that this interpretation should be considered with caution. It should, however, be noted that networks involving mPFC activity have consistently been linked to socially dominant behaviours even across a more general biological conceptualisation of this phenotype across species 27 , 65 , 66 , 67 , 68 , which warrants further studies of its overlap with the narcissistic phenotype studied in our sample.

Our study only found minor interactions of sex and narcissism in its relation to brain structure. While we need to consider that our sample showed only minor differences in narcissism (sub)scales between females and males, it might lack generalisability in that respect (as gender differences have been shown in large meta-analyses 21 ). The few findings of a sexually dimorphic effect were, however identified in the lateral prefrontal cortex and thus no effects or trends were observed in medial prefrontal, orbitofrontal, or insular cortices.

Finally, we need to consider a few limitations of our study, including the moderate sample size, which is also a potentially limiting factor in identifying sex interactions and correlations to those subscores, which are based on a smaller number of NPI items, as well as the lack of functional MRI analyses. While our choice of the NPI was guided based on its wide-spread application in the past, it might not cover some aspects of narcissism as well as other inventories, and further studies are needed to differentiate the contribution of, for example, entitlement vs. vulnerability to the different prefrontal network nodes. Despite our support for prefrontal involvement in narcissism, the current evidence across the few available studies is not unequivocal, and additional studies using more fine-grained phenotyping as well as possibly additional imaging modalities are needed to further corroborate the available evidence, which is non unequivocal.

One major limitation is specificity: as our phenotyping only included the NPI, which defines a complex, multi-faceted narcissism phenotype, we cannot exclude the possibility that other, less-specific factors or even traits unrelated to narcissism (e.g. neuroticism) might similarly have explained variance in the identified brain structure. Further studies with more in-depth phenotyping would be necessary to ascertain specificity and better characterise which singular facets of narcissism or related traits might drive the associations to different brain areas, esp. across the prefrontal cortex. Nevertheless, our study is a potentially important advance over previous studies, as it shows for the first time, using a robust imaging and statistical approach, that multiple prefrontal and insular cortical areas are correlated with the expression of narcissistic traits, even in the absence of manifest pathology.

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Acknowledgements

Parts of this study were supported by a Junior Scientist Grant of the Friedrich-Schiller-University of Jena (to I.N.). We would like to thank all colleagues at the Department of Psychiatry and Psychotherapy in Jena for their help and assistance with subject recruitment and scanning, in particular Dr. Kerstin Langbein and Dipl.-Psych. Maren Dietzek, who both contributed immensely to the lab’s MR studies, from which this cohort was drawn, as well as the technicians of the Institute of Diagnostic and Interventional Radiology, Jena University Hospital, for their help with scanning.

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I.N. conceived of the study and its design, obtained funding, supervised recruitment, MRI scanning and data analysis, interpreted data, and wrote the manuscript. C.L. analysed MRI data under supervision. C.G. supervised MRI data analysis and consulted on methodology. All authors commented on the first draft and approved of the final version of the manuscript.

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Nenadić, I., Lorenz, C. & Gaser, C. Narcissistic personality traits and prefrontal brain structure. Sci Rep 11 , 15707 (2021). https://doi.org/10.1038/s41598-021-94920-z

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Narcissistic personality disorder: an integrative review of recent empirical data and current definitions

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• 1 Department of Psychiatry, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Eschenallee 3, 14050, Berlin, Germany, [email protected].
• PMID: 24633939
• DOI: 10.1007/s11920-014-0445-0

Although concepts of pathological narcissism are as old as psychology and psychiatry itself, only a small number of clinical studies are based on the criteria for narcissistic personality disorder (NPD), as defined in the Diagnostic and Statistical Manuals of Mental Disorders (DSM). As a result, NPD appears to be one of the most controversially discussed nosological entities in psychiatry. Whereas the majority of empirical studies used self or other ratings of NPD criteria to address issues of reliability and validity of the diagnostic category (i.e., internal consistency, factor structure, discriminant validity), only recent research has applied experimental designs to investigate specific features of NPD (e.g., self-esteem, empathy, shame). The aim of this review is to summarize available empirical data on NPD and relate these findings to current definitions of NPD (according to the DSM-5, [1]). In order to do so, this review follows the five steps to establishing diagnostic validity proposed by Robins and Guze [2], i.e., (1) clinical description, (2) laboratory studies, (3) delimitation from other disorders, (4) family studies, and (5) follow up studies. Finally, this review suggests pathways for future research that may assist further nosological evaluation of NPD and contribute to the overall goal, the improvement of treatment for patients.

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Pathological Narcissism and Narcissistic Personality Disorder: Recent Research and Clinical Implications

• Personality and Impulse Control Disorders (R Lee, Section Editor)
• Published: 19 January 2016
• Volume 3 , pages 34–42, ( 2016 )

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This review is focused on integrating recent research on emotion regulation and empathic functioning with specific relevance for agency, control, and decision-making in narcissistic personality disorder (NPD, conceptualized as self direction in DSM 5 Section III). The neuroscientific studies of emotion regulation and empathic capability can provide some significant information regarding the neurological/neuropsychological underpinnings to narcissistic personality functioning. Deficiencies in emotion processing, compromised empathic functioning, and motivation can influence narcissistic self-regulation and agential direction and competence in social interactions and interpersonal intimate relationships. The aim is to expand our understanding of pathological narcissism and NPD and suggest relevant implications for building a collaborative treatment alliance.

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Ronningstam, E. Pathological Narcissism and Narcissistic Personality Disorder: Recent Research and Clinical Implications. Curr Behav Neurosci Rep 3 , 34–42 (2016). https://doi.org/10.1007/s40473-016-0060-y

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Narcissistic Personality Disorder: Are Psychodynamic Theories and the Alternative DSM-5 Model for Personality Disorders Finally Going to Meet?

Frans schalkwijk.

1 Department of Forensic Special Education, University of Amsterdam, Amsterdam, Netherlands

Patrick Luyten

2 Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom

3 KU Leuven, Leuven, Belgium

Theo Ingenhoven

4 Arkin, Amsterdam, Netherlands

Jack Dekker

5 Department of Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands

Narcissistic Personality Disorder is the new borderline personality disorder of our current era. There have been recent developments on narcissism that are certainly worthwhile examining. Firstly, relational and intersubjective psychoanalysts have been rethinking the underlying concepts of narcissism, focusing on the development of self and relations to others. Secondly, in the DSM-5, the Alternative DSM-5 Model for Personality Disorders (AMPD) was presented for a dimensional evaluation of the severity of personality disorder pathology. The combined dimensional and trait conceptualization of NPD opened the door to new integrated diagnostic perspectives, including both internal and interpersonal functioning. Finally, Pincus and Lukowitsky encourage clinicians to use a hierarchical model of pathological narcissism, as it opens up opportunities for shared points of interest in empirical research from different scholarly perspectives. As for most non-psychodynamic clinicians and researchers the DSM-5 clearly bears dominant weight in their work, we will take the AMPD model for NPD as our point of reference. We will discuss the narcissist's unique pattern of self-impairments in identity and self-direction, and of interpersonal disfunctioning (evaluated by assessing empathy and intimacy). Subsequently, we will examine how contemporary psychodynamic theories and the hierarchical model of Pincus and Lukowitsky additionally inform or contradict the AMPD. For us, one of the big advantages of the AMPD is the use of structured clinical evaluations of disturbances of the self and interpersonal functioning and the dimensional evaluation of severity. As psychodynamically oriented therapists, we are enthusiastic about the opportunities for inclusion of psychodynamic concepts, but we also discuss a number of sticking points.

Introduction

Narcissistic Personality Disorder is the new borderline personality disorder of our current era (Choi-Kain, 2020 ). After three decades of progress have been made on Borderline Personality Disorder (BPD), Narcissistic Personality Disorder (NPD) now “… carries the potential for a new wave of investigation and treatment development.” Originally, narcissism was a psychoanalytic concept developed by Freud ( 1914 ). It became a dominant theme in the 1970s in the fierce debate between the psychoanalysts Kernberg ( 1975 ) and Kohut ( 1972 ). In the years that followed, few psychodynamic theoretical advances were made and research was scarce (as can be seen in Glasmann, 1988 ; Heiserman and Cook, 1998 ). However, in 1980, “given the increasing psychoanalytic literature and the isolation of narcissism as a personality factor in a variety of psychological studies,” narcissism found its way into the third Diagnostic and Statistical Manual of Mental Disorders (DSM-III; Frances, 1980 , p. 1053). Narcissism had established a foothold in the diagnostic “bible.” In the decades since, a robust body of research has not developed to test or substantiate Frances' assumption that narcissism is a specific personality factor. In a recent online literature search on PubMed, Choi-Kain ( 2020 ) found 27 times more articles for BPD than for NPD. Even worse, research has found a significant overlap between the diagnostic criteria for all personality disorders in DSM-IV and extreme heterogeneity in patients with the same diagnosis (American Psychiatric Association, 2011 ). This conclusion was particularly clear in the case of NPD (Miller et al., 2010 ; Pincus, 2011 ). Not surprisingly, in the discussion preceding the publication of the DSM-5 (American Psychiatric Association, 2013 ), there was heated debate about radical changes to the criteria for personality disorder (Skodol et al., 2011 ; Oldham, 2015 ). Thirty years after the inclusion of NPD in the DSM-III, it was almost removed from the fifth edition.

However, in the past two decades, there have been developments relating to narcissism that certainly merit examination. Firstly, relational and intersubjective psychoanalysts have been rethinking the concepts underlying narcissism, focusing on the development of self and relations to others (Drozek, 2019 ). Secondly, an Alternative DSM-5 Model for Personality Disorders (AMPD) was established in the DSM-5 for the dimensional diagnosis of personality disorders alongside the strict categorical classification of personality disorders that had been used until then (Bender et al., 2011 ; American Psychiatric Association, 2013 ; Skodol et al., 2014a ). In particular, the combined dimensional and trait conceptualization of NPD opened the door to new integrated diagnostic perspectives, including both internal and interpersonal functioning (Ronningstam, 2020a ). Finally, Pincus and Lukowitsky's ( 2010 ) proposal for a hierarchical model of pathological narcissism opens up the prospect of looking beyond the relatively minor differences between competing theories about narcissism in order to find common ground.

In this article, we will examine if and how these recent developments can be integrated. We begin by providing an overview of contemporary psychodynamic theories on narcissism, followed by a description of the hierarchical model of narcissism and the AMPD for NPD.

New Theoretical Developments

Contemporary psychodynamic theories on narcissism.

An important question, clinically and conceptually, is what motivates human beings and makes them human. The traditional drive model posits that we are motivated by derivatives of innate aggression and sexual desires that can destabilize the ego or self. In recent decades, contemporary psychodynamic thinking has enriched conceptual knowledge about the motivational etiology and expression of narcissism. Turning away from the drive model implies relinquishing the assumption of specific narcissistic needs or a specific narcissistic phase in child development (Meissner, 2008 ). Instead, contemporary relational psychoanalysis focuses on attachment, mentalization, relational needs, and motivational affective systems (Modell, 1993 ; Panksepp, 1998 ; Akhtar, 1999 ; Meissner, 2009 ; Lichtenberg et al., 2011 ). As humans, we strive for development and homeostasis in self-organization, with biological and emotional forces playing an important role.

What shape does this take in optimal developmental circumstances? Self-organization develops with the adequate fulfillment of the emotional needs of babies and toddlers for attachment and emotion regulation (Schore, 2003 ). These needs are met in reciprocal interaction with significant others and represented in the brain as internal working models about the self, relations, and others (Bebee and Lachmann, 2002 ). In this development, the theory of object relations theory is also important. However, in the newer theories, the “relations” are based on a two-person psychology. These implicit working models are the materials for the “self-as-agent,” for sensing that you can prevent or make things happen. It is the blueprint for developing capacities for emotion regulation, attachment, mentalizing, reflective functioning, empathizing, and epistemic trust (Fonagy, 2003 ). As babies and toddlers have no capacity for speech and symbolic thinking, the self-as-agent remains implicit and can only be experienced by enacting it.

As the capacity for language and symbolizing increases, however, preschoolers arrive at the realization of the self as a subject that experiences emotion: the self-as-subject develops. The self-experience of a preschooler is relatively conscious as a person who gives meaning to his or her life and is separated from, while simultaneously attached to, significant others (Gergely and Unoka, 2008 ). Especially after the age of seven, the capacity for reasoning grows spectacularly and the child develops the capacity to self-reflect with a bird's eye view. Consequently, the self-as-object becomes integrated in a firmer sense of identity and the child constantly self-evaluates as in an inner dialogue (Meissner, 2008 ). The growing capacity for self-evaluation develops alongside the capacity to experience self-conscious emotions such as shame, pride, jealousy, and envy (Wurmser and Jarass, 2008 ; Schalkwijk, 2015 , 2018 ).

We will now look at how this relational theory of self-organization can be applied to narcissism. The most important factor is the chronic frustration of the basic biological need for satisfying reciprocal interactions. A child's or toddler's frustration sets the scene for the development of dysfunctional capacities for emotion regulation, attachment, mentalizing capacities, reflective functioning, and empathizing. The self-as-agent feels more powerless than able to make things happen. Ronningstam ( 2020b ) writes: “As a central aspect of narcissistic functioning, sense of agency influences both self-regulatory and interpersonal functioning, such as attention seeking, competitiveness, and achievements” (Ronningstam, 2020b , p. 91). These hampered capacities are part of the implicit self and thus operate outside of conscious awareness in the adult; they are ego-syntonic. Meissner ( 2008 ) and Symington ( 1993 ) suggest that, although not enacted “consciously” in the adult sense, the child has turned away from reciprocal interaction with others to protect his or her growing implicit self from chronic disappointment, from experiencing powerlessness instead of agency. Turning away from potentially frustrating interaction with significant others and opting for self-absorption is the core feature of pathological narcissism (Auerbach, 1993 ; Lachmann, 2007 ). This can already be observed in preschoolers. Brummelman et al. ( 2016 ) showed that preschoolers with a high score for either self-esteem or narcissism are differentiated by the latter verbalizing that they are great, others are stupid, interaction with others is frustrating, and one is better off on one's own. Those with high scores for self-esteem verbalized that they are great, others are great too, and working together will make the results better. This can also be seen in adult life. When one of our patients was persuaded by his children to play his computer games in the living room instead of sitting in the attic, he said: “I see no additional value in sitting downstairs. It is irritating as my daughters want me to get involved in what they are watching on TV.” Basically, the patient was unable to experience the pleasure of being with someone. Inevitably, by turning away from others, a frail self-as-subject results, as it is built on frustrating self and other representations that miss benevolent, soothing, and realistic qualities. As a result, self-regulation is further impaired as the development of the self-as-object is hampered as well. The capacity for self-knowledge through reflection on the subjective self is underdeveloped, protecting the subject from painful shame (Meissner, 2008 ). Consequently, in an unfortunate cumulation of hampered development, all aspects of the self are frail and self-regulation is dysfunctional.

Another relatively new psychodynamic theory, intersubjective psychoanalysis, has more to say about the dynamics of narcissism (Benjamin, 2018 ; Drozek, 2019 ). By contrast with the basic need for satisfying reciprocal interactions posited by relational psychoanalysis, intersubjective psychoanalysis stresses the intrapsychic motivation for the intention to relate. Imagine not only being motivated by biological needs but also being intrinsically motivated to relate (“just for the fun of it”). Imagine wishing to recreate being in a relationship with another and re-experiencing the fulfillment that gives. According to Benjamin ( 2018 ), this makes human beings fundamentally subjects who unconditionally value themselves and the other as individually dignified. Another fundamental characteristic of narcissism, in addition to incoherent self-organization, is a severe impairment of the intrinsic motivation to seek nearness and recognize the other as a subject.

In the next section, we will explore the trauma of narcissism and the associated suffering. Drozek ( 2019 ) states that patients with severe pathological narcissism (or borderline problems) find it impossible to value themselves unconditionally or ascribe unconditional value to others. They are therefore unable to be motivationally receptive to the subjectivity of others. “Rather, these patients are often only valuing aspects of the other (e.g., attentiveness, admiration, dependency) and valuing themselves only conditionally (e.g., contingent on their ability to appease the other)” (Drozek, 2019 , p. 93). In this paper, we will not enter into the therapeutic implications of an intersubjective stance of this kind. We will go no further than pointing out that the therapist should actively assume responsibility for repairing ruptures in the relationship between the patient and the therapist (Benjamin, 2018 ). Recognition from the therapist is insufficient for change; patients should also be actively engaged in recognizing themselves and the therapist/others. Recognition implies owning one's vulnerability and harmful aspects instead of projecting them onto the other.

The lack of intrinsic motivation for relating is associated not only with psychological distancing from and only conditionally valuing others, but also with another recent theoretical focus, namely, attachment theory. Diagnostically, one would expect insecure attachment styles. The lack of intrinsic motivation for relating would then emerge in a dismissive-avoidant attachment style, whereas the extrinsic motivation for relating, as seen in excessive reference to others for self-enhancement, would be seen in a preoccupied attachment style. Research into the relationship between pathological narcissism and attachment styles is scarce but it is growing. Banai et al. ( 2005 ) suggest that the painful longing for others to fulfill one's own needs may be a motivational component of attachment avoidance: “I don't need you!” Exploring early life experiences in a non-clinical sample, Cater et al. ( 2011 ) showed that narcissistic dynamics like entitlement, grandiosity, and vulnerability were associated with different parenting styles. Summarizing the research findings to date, Diamond et al. ( 2013 ) conclude: “Narcissistic disorders have been associated with dismissing-avoidant attachment status (…) but patients may also be characterized by preoccupied attachment status, in which the individual remains angrily or passively enmeshed with attachment figures” (Diamond et al., 2013 , p. 533; see also: Ronningstam, 2020b ).

In the clinical and research literature, we see specific countertransference feelings in narcissistic patients as valuable contributions to the diagnostic process. In a clinical sample, independent of the therapist's theoretical orientation, age, or gender, NPD was positively associated with criticized/mistreated and disengaged countertransference, and negatively associated with a positive therapist response (Tanzilli et al., 2015 , 2017 ). Further research in a sample of adolescents showed that grandiose narcissistic traits were associated with angry/criticizing and disengaged/hopeless therapist responses, whereas warm/attuned therapist responses fell short (Tanzilli and Gualco, 2020 ). In addition, the quality of the therapeutic alliance was lower. Adolescents with hypervigilant traits received overinvolved/worried therapist responses and few angry/criticized responses 1 .

These countertransference reactions may indicate a dismissive attachment style in the patient. The negative association with positive therapist response confirms our clinical experience. As a patient said: “When you are so kind to me, I want to hit you!” The therapist's kindness or benevolence evokes shame: the patient, who is in a help-seeking, dependent position, finds the therapist's kindness humiliating. Envy can be used as a defense against shame: the patient envies the therapist's superiority and wants to take it away from him or her (Morrison and Lansky, 2008 ). The dynamics between shame and envy express themselves in a self-focused competitive view of others that is considered to be a characteristic of narcissism. All relations here are thought to be about winning or losing, and mutual advantage is an unthinkable reality, as seen in the aforementioned research with preschoolers by Brummelman et al. ( 2016 ).

In this paper, we depart from this contemporary relational and intersubjective line of psychodynamic theorizing, with characteristics such as the loss of reciprocal interaction, the loss of intrinsic motivation for seeking nearness, ascribing only conditional value to oneself and others, frail self-regulation, and the absence of the self-as-object. More traditional psychodynamic theories will not be replaced or dismissed and will continue to be referred to when applicable. Throughout this paper we will also refer to the Psychodynamic Diagnostic Manual, Second Edition (PDM-2, Lingiardi and McWilliams, 2017 ). The PDM-2 focuses on personality styles and not on personality disorders. Personality styles are “a relatively stable confluence of temperament, attachment style, developmental concerns, defenses, affect patterns, motivational tendencies, cultural influences, gender and sexual expressions and other factors–irrespective of whether that personality style can be reasonably conceptualized as ‘disordered”' (McWilliams et al., 2018 , p. 299). The term personality disorder is used for personality styles “denoting a degree of extremity or rigidity that causes significant disfunction, suffering, or impairment” (Lingiardi and McWilliams, 2017 , p. 17). The PDM-2 is based on the integration of the vast body of clinical experience with the richness of empirical research, thus departing from the DSM-5's fundament of empirical research only. In contrast to the DSM-5's striving for simplicity by ascribing fixed patterns of symptoms, the fundamental psychoanalytic premise in the PDM-2 is that doing complexity justice by acknowledging that “opposite and conflicting tendencies can be found in everyone (McWilliams et al., 2018 , p. 300).”

The Hierarchical Model of Narcissism

Synthesizing theories about narcissism with the results from research and leaving the “narcissism of minor differences” behind, Pincus and Lukowitsky ( 2010 ) proposed that pathological narcissism is best conceptualized by a hierarchical model (see Figure 1 ). In their view, pathological narcissism is basically characterized by a combination of three psychodynamic phenomena: dysfunctional self-regulation, emotion regulation, and interpersonal relations.

Pincus and Lukowitsky's model of narcissism.

They consider these three dysfunctional phenomena to represent the most basic building blocks of pathological narcissism. From this perspective, in contrast to the DSM-5 NPD classification, the Pincus and Lukowitsky model allows pathological narcissism to be situated on a continuum between two prototypes, which are covered by different terms in the clinical and research literature. At one end of the spectrum we find the prototype of grandiose, thick-skinned, arrogant/entitled, shameless, oblivious narcissism (PDM Task Force, 2006 ; Gabbard, 2015 ). At the other end, we see the prototype of vulnerable, thin-skinned, hypervigilant, shame-prone, depressed/depleted narcissism: “This narcissistic vulnerability is reflected in experiences of anger, envy, aggression, helplessness, emptiness, low self-esteem, shame, social avoidance, and even suicidality” (Pincus, 2013 , p. 95; italics Pincus). Although empirical evidence is still lacking, Pincus and Lukowitsky assume that grandiose and vulnerable narcissism can express themselves both overtly and covertly. “Thus, we might diagnose a patient with grandiose narcissism, with some elements being expressed overtly (behaviors, expressed attitudes and emotions) and some remaining covert (cognitions, private fantasies, feelings, motives, needs)” (Pincus, 2013 , p. 96).

An interesting line of research was adopted by Russ et al. ( 2008 ) with the Shedler-Westen Assessment Procedure. They used atheoretical Q-sort methodology to identify, in addition to those described by Pincus and Lukowitsky, two subtypes of narcissistic personality disorder, as well as a high-functioning/exhibitionistic subtype. Patients with this third subtype, who are well represented in the clinical literature, “have an exaggerated sense of self-importance, but are also articulate, energetic, and outgoing. They tend to show good adaptive functioning and use their narcissism as a motivation to succeed” (Russ et al., 2008 , p. 1479). This third subtype could be the prototype of the positive side of narcissism, a line which has not received much attention.

In their model, therefore, pathological narcissism is basically characterized by a dysfunctional regulation of self, emotions, and relations, which is remarkably consistent with contemporary relational psychodynamic theorizing. Pathological narcissism can therefore be situated between the poles of grandiose and vulnerable narcissism, which is consistent with traditional psychoanalytic theorizing but not with the original NPD concept in DSM-III and later editions. The idea that narcissism can express itself overtly and covertly is consistent with traditional psychoanalytic theory.

The Alternative Model for Personality Disorders

As stated above, the American Psychiatric Association (APA) discussion about the classification of personality disorders led to two different classification approaches in DSM-5. The first classifies the patient as usual in one of the official ten personality disorder categories, as described in section II of DSM-5. Clinicians and researchers can also adopt the new AMPD approach described in section III to assess patients' level of personality functioning and their unique trait profile. The assessment then consists of a mixture of clinical evaluation and the use of standardized instruments (Skodol et al., 2014b ; Berghuis et al., 2017 ). In the AMPD, each personality disorder is characterized by a specific pattern of personality disfunctions and traits. In the case of narcissistic personality disorder, there is a unique pattern of self-impairment in identity and self-direction, and of impaired interpersonal functioning in empathy and intimacy. An NPD diagnosis is justified when at least two of these four elements are moderately or severely impaired. The specific traits to be assessed are grandiosity and attention seeking. It is interesting to note that, in PDM-2, the level of severity is established along the lines of Kernberg's concept of neurotic, borderline, and psychotic personality organization (Lingiardi and McWilliams, 2017 ).

In the next section, we will address the four AMPD elements of personality functioning and its specified traits on the basis of current psychodynamic concepts and the hierarchical model described above.

Reflection on Personality Impairments in Narcissism

In order to integrate the recent developments discussed here, we need a point of reference. As is the case for most non-psychodynamic clinicians and researchers, DSM-5 clearly plays a role in our work, and so we will adopt the AMPD model for NPD as our point of reference. Subsequently, we will examine how contemporary psychodynamic theories and the hierarchical model of Pincus and Lukowitsky additionally inform or contradict the AMPD.

Evaluating Impairment of Identity

The AMPD conceptualizes identity impairment as:

• - excessive reference to others for self-definition and self-esteem regulation;
• - exaggerated self-appraisal, inflated or deflated, or vacillating between extremes; and
• - emotional regulation mirrors fluctuations in self-esteem (American Psychiatric Association, 2013 , p. 776).

This conceptualization addresses the function of others for self-definition and self-esteem regulation. Reference to others for self-definition is adequately described in traditional psychodynamic theorizing. Kohut ( 1972 ) emphasizes how the patient uses others instrumentally as objects for enhancing the patient's self, calling them “self-objects.” As soon as others no longer fulfill that function, their instrumental value becomes zero, and they are devalued as losers and discarded. Although this could appear to be counterintuitive, we argue that this applies not only to grandiose, but also to vulnerable, narcissism. In the latter, the patient enhances self-esteem by placing others in the spotlight.

Another counterintuitive combination is the AMPD's stress on “excessive reference to others” and the psychodynamic view that narcissism implies a refusal of reciprocal interaction with others and a lack of intrinsic motivation for nearness. The key to bringing together these seemingly different foci lies in the answer to the question “excessive reference to which self and which others?” The implicit self is consciously verbalized as a subjective self on the lines of: “I do not want to think and talk about the distress of my partner; I cannot bear it. It is too threatening to myself.” The narcissistic patient refuses to recognize the unconditional value of the other and to live in a reciprocal world. Indeed, others do “excessively” matter but not as unconditionally valuable subjects: their relational value depends on the instrumental function they serve for the regulation of the patient's self-esteem. We agree with Meissner ( 2008 ), who sees narcissism as a psychodynamic function motivated by the need for “self-definition, self-development, self-organization, self-preservation, self-cohesion, self-enhancement, self-evaluation, self-regard, and self-esteem” (Meissner, 2008 , p. 768). We are in favor of interpreting the strong focus on self-definition in AMPD's NPD as a focus on striving for coherence of identity. As for the quality of the excessive reference to others, we should not forget that, even if this reference becomes explicit, it is still located in the internal framework of a dysfunctional implicit self. Fonagy et al. ( 2002 ) add that the dysfunctioning of the self is further caused by the underdevelopment or absence of the self-as-object. Self-reflection and introspection are therefore impaired, and so is self-knowledge.

Identity is further conceptualized in the AMPD as “Self-appraisal inflated or deflated, or vacillating between extremes” and “Un-nuanced: self-loathing, self-aggrandizing, or an illogical, unrealistic combination” (American Psychiatric Association, 2013 , p. 777). Likewise, in the PDM-2, the narcissistic personality style's central tension or preoccupation is inflation vs. deflation of self-esteem, whereas defense organization is dominated by idealization and devaluation (Lingiardi and McWilliams, 2017 ). Combining this definition with psychodynamic theorizing, we must differentiate between two diagnostic groups. In patients with narcissism, the subconscious dysfunctional regulation of the subjective self lies in its incoherence, in the vacillation between black-and-white opposites of idealization and devaluation. The patient is therefore engaged in a constant struggle with himself or herself; even narcissistic grandiosity co-occurs with insecure self-representations and sensitivity to rejection (Kealy et al., 2015 ). Caligor ( 2013 ) maintains that “as identity pathology becomes more severe, overt pathology in the sense of self as in the sense of others emerges” (Caligor, 2013 , p. 71). In the other group who could fit this description, however, patients consciously suffer from low self-esteem. Their self is consciously experienced as consistently defective in only one direction: failing and coming up short.

Finally, the third element of identity impairment is “emotional regulation mirrors fluctuating self-esteem” (American Psychiatric Association, 2013 , p. 777). In narcissism, emotions follow momentary self-esteem states whereas, in BPD, for example, self-esteem would appear to follow emotions more. One of our patients reported that her weekend had been depressing. She had frequently tried to help friends but, in the end, none of them had needed her. Where did that leave her? She felt useless and therefore depressed. The link between self-esteem and dysfunctional emotion regulation is characteristically expressed in the concept of narcissistic rage: the patient is extremely vulnerable to humiliation (perceived or otherwise) and strikes out when others are disappointing (Kohut, 1972 ). The PDM-2 focuses on shame, humiliation, contempt, and envy as central affects (Lingiardi and McWilliams, 2017 ). In a study of grandiose narcissism, shame was found to act as a mediating factor, reducing levels of aggression in patients with perfectionistic traits (Fjermestad-Noll et al., 2020 ). Clinically, this vulnerability is strengthened by the experience of shame when identity is negatively evaluated. Much more than guilt, shame is associated with falling short of one's expectations of an ideal, grandiose self. Shame is differentially associated with the aspect of grandiosity vs. vulnerability. Generally, shame is absent or warded off in grandiose narcissism, whereas grandiose fantasies can alternate with intense shame about needs and ambitions in vulnerable narcissism (Gramzow and Tangney, 1992 ; Dickinson and Pincus, 2003 ; Ronningstam, 2005 ). A more recent explanation for this fluctuation is that some patients with NPD tend toward mental concreteness, a refusal of symbolization or not symbolizing (Ronningstam, 2020b ). This certainly has severe implications for the therapeutic alliance, the limitation of latitude for interpretation, and countertransference in the therapist.

Evaluating Impairment of Self-Direction

The AMPD conceptualizes the impairment of self-direction as: “Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement while frequently unaware of one's own motivations” (American Psychiatric Association, 2013 , p. 767). The PDM-2 also describes as characteristic the pathogenic belief about self that “I need to be perfect to feel OK,” whereas the pathogenic belief about others is: “Others enjoy riches, beauty, power, and fame; the more of those I have, the better I will feel” (Lingiardi and McWilliams, 2017 ).

With respect to the element of “goal setting based on gaining approval from others,” our clinical experience is that the patient can experience approval with no connection to reality. Consequently, others do not have to express their gratitude or approval in order to fulfill their instrumental function. In the splendid isolation of covert narcissism, admiring others can very well be imaginary: “Once I have published my solution for the global warming problem, everybody will admire me.” The internal (and possibly hidden) goal setting, which can take place in fantasy or daydreaming and with no footing in reality, is a particular inaptness in goal setting in covert narcissism that can be easily overlooked by clinicians.

The general inaptness of personal standards that is mentioned in the AMPD is clinically highly recognizable and consistent with psychodynamic theorizing. The suggested associations between “high standards and being exceptional” vs. “low standards and being entitled,” however, do not do justice to the converse clinical reality that high goal setting may also be based on the belief of being entitled and low goal setting on the belief of being exceptional anyway. Psychodynamic authors have provided good descriptions of the psychodynamics of shifting defenses in narcissism, in other words the warding of one emotion with another. For example, a patient can feel exceptional by setting extremely low standards, as in the patient mentioned above: “Once I have published my solution for the global warming problem, everybody will admire me. It's all in my mind, I just have to write it up when I feel it's time to do so.” Until then, the patient will just go on as usual, keeping a low profile.

Finally, AMPD and psychodynamic theorizing match up straightforwardly in the idea of being “often unaware of one's own motivations”: self-knowledge has to be avoided at any cost and often the patient has no conscious knowledge of struggling with his or her self-esteem or identity. We have already described the phenomenon in which the less patients can reflect upon themselves—an indication of weak reflective functioning—the more pathological narcissism is likely. To the best of our knowledge, little research has been conducted until now that specifically addresses the ability of reflective functioning in narcissistic patients (Diamond et al., 2013 , Ronningstam, 2020b ).

In our clinical experience, narcissistic patients live their lives and use treatment at their own pace: “Time is on my side.” This makes treatment targeting inner change extremely difficult and time-consuming. Making narcissistic dynamics egodystonic and sensitizing the patient to hidden motives is one thing but handling the high levels of shame and anxiety that accompany the uncovering of the implicit self, which the patient feels compelled to ward off, is another (Steiner, 2011 ).

Evaluating Interpersonal Impairment in Empathy

With the discussion of empathy, we enter the world of interpersonal difficulties encountered by narcissistic patients. The AMPD conceptualizes empathy as the: “Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- and underestimate of own effects on others” (American Psychiatric Association, 2013 , p. 767).

The aspect of “impaired ability to recognize or identify with the feelings and needs of others” fits in well with Pincus and Lukowitsky's hierarchical model of pathological narcissism. In that model, impairment in interpersonal functioning is one of the three basic features of narcissism. Narcissism is accompanied by an impaired ability to identify the feelings and needs of others, the failure to recognize the other as a subject in her or his own right, and blocking reciprocity and mutual affect regulation (Ritter et al., 2011 ). The patient does not expect to benefit from sharing emotions and is not intrinsically motivated to seek nearness. The impairment in empathy is not only found in impaired mentalizing: as patients are not willing to focus their attention on the other, they will also not want to respond emotionally to what can be experienced through empathy (Allen et al., 2008 ). In clinical practice, the therapist's empathic interventions are often warded off by an empathic wall : “I don't want to be understood by you” (Nathanson, 1986 ).

The qualification of the patient as being “excessively attuned to reactions of others, but only perceived as relevant to self” is very apt. In as much as others do not threaten to destabilize the patient's self-esteem, they are not in the patient's mind. If empathy does come into play, the quality of empathy is most likely to be extremely poor as others are perceived on the basis of the patient's subconscious blueprint of the implicit self. In research literature on empathy, there is a distinction between affective and cognitive empathy, which are represented in two different neural circuits (Fonagy et al., 2002 ; Cuff et al., 2016 ). Clinically, if the patient has some empathic awareness of the other, we would expect cognitive empathy to be more associated with grandiose narcissism, and affective empathy to be more associated with vulnerable narcissism. Research, however, does not support our clinical experience: NPD patients have significant impairments in affective empathy, whereas cognitive empathy seems largely unaffected. Despite our clinical experience, Ronningstam ( 2020b , p. 84–85) concludes: “Further studies have provided evidence for compromised empathic function in NPD, that is, intact cognitive but neural-deficient emotional empathy, and impact of emotion intolerance and processing on ability to empathize (Ritter et al., 2011 ).”

Evaluating Interpersonal Impairment in Intimacy

The AMPD conceptualizes intimacy as follows: “Relationships are largely superficial and exist to serve self-esteem regulation; mutually constrained by little interest in other's experiences and predominance of a need for personal gain” (American Psychiatric Association, 2013 , p. 767). Relationships of this kind are related to the etiology of pathological narcissism represented in the blueprint of the implicit self: the inner representations of others are not based on an integration of differentiated images of self and others, nor are others recognized as autonomous subjects. Indeed, patients only send; they do not receive and they refuse reciprocity in relations with others. They hardly engage at all in inner self-talk as someone with a well-developed self-as-object would do to acquire more self-knowledge. It should be remembered that others are not seen as persons in their own right but rather experienced and used as instruments. In our clinical experience, therapists (and others) are most valued if they maintain an emotional distance and refrain from empathic interventions. This was seen in the example quoted above of the patient who said: “When you are so kind to me, I want to hit you!”

The need for personal gain can easily be misunderstood: the benefit is found in the enhancement of the subjective self. The instrumentality of relationships is a defense against the unbearable feeling of being dependent on the relationship (Kernberg, 1975 , 1984 ). The exploitative quality of relations looks superficially like a “gain” but as therapists we should not forget that this gain involves a price: the patient lacks the capacity for self-soothing and existential loneness results. Characteristically, others are usually idealized or devaluated excessively and inappropriately. The patient may hyper-idealize others in order to comfortably warm him- or herself in the heat of their radiance: “Look how great we are!” (“mirror transference,” Kohut, 1972 ). Hyper-idealizing someone also places the patient in the position of being the one who has the expertise to judge, which fuels feelings of superiority. Excessive devaluation comes to the fore if the existence of the other threatens the stability of the subjective self by association: “Who am I, if I am associated with that loser?” A patient said to one of us: “Are you divorced? Because if you are, how can you help me with my relational problems when you can't handle them yourself?” The often bitter and aggressive nature of devaluation serves to enhance the subjective self. Idealization and devaluation are associated with an insecure dismissing-avoidant attachment style (Tolmacz and Mikulincer, 2011 ). Ambivalence is seldom cherished as a valuable state of mind; instead, relations are about winning or losing, and jealousy is omni-present.

Anything with relational implications will be dismissed if it might give pleasure and make one emotionally alive. The evaluation of anniversary gifts is exemplary: a patient with grandiose narcissism said: “Getting presents for my anniversary is only a means of bringing more worthless trash into my house.” His vulnerable counterpart always bought himself a present after his birthday, shielding himself from the disappointment that others may not give him the “right” presents. Describing the basic relational patterns of patients with NPD, Lachkar ( 2008 ) writes that their partners are quite often diagnosed with BPD. It is a tale of the deaf leading the blind and, usually, the relationship falters when the partner with BPD matures and becomes less dependent and anxious.

Sexuality in relationships is often complicated. The patient tries to avoid the humiliation of having to display needs and wishes, and of experiencing vulnerability: “Hell is other people,” said Sartre ( 1943 ). Psychoanalyst Green adds to Sartre's dictum: “Hell is not other people, but rather the body. … The body is a limitation, a servitude. … The body is his absolute master–his shame” (Green, 1997 , p. 127). Sexuality is often reduced to a mere physical pleasure, whether or not permeated with fantasies of being the greatest lover. Extreme self-centeredness or other-centeredness during lovemaking is characteristic, as reciprocity and empathic attunement are avoided. The partner is treated instrumentally: “What value does the other's sexual pleasure have for myself as a lover?” A male patient broke up his marriage after discovering he had been lied to for years: with great shame, his wife had told him she was unorgiastic and had faked orgasms. His self-worth as a great lover crumbled.

Sexuality can turn into perverse love: sexual excitement becomes the substitute for love and the longing of the other serves to strengthen the cohesion in the self. The own body, the other's body, or a fetish becomes a sexual object, an eroticized self which is constantly longing for stimulation (Akhtar, 2009 ). It is not uncommon to find NPD patients who also suffer from hypochondria: the frail implicit self has developed alongside a frail bodily self.

Reflection on the Narcissistic Personality Traits of Grandiosity and Attention Seeking

It should be remembered that the AMPD characterizes each personality disorder on the basis of a specific pattern of personality dysfunctions and traits. In the section above, we described the patterns of this pattern in NPD by looking at a unique pattern of self-impairments, which are evaluated by focusing on identity and self-direction, and of interpersonal functioning, which is evaluated by focusing on empathy and intimacy. We now turn to the unique trait profile of NPD: grandiosity and attention seeking.

Evaluating Personality Traits: Grandiosity

The AMPD conceptualizes grandiosity as “Feelings of entitlement, either overt or covert; self-centeredness, firmly holding to the belief that one is better than others; condescension toward others” (American Psychiatric Association, 2013 , p. 768).

The description of feelings of entitlement, either overt or covert, fits in well with Pincus and Lukowitsky's ( 2010 ) suggestion that grandiose and vulnerable narcissism can be expressed both overtly and covertly and, consequently, that feelings of entitlement should not only be associated with grandiose narcissism. This perspective confirms our clinical experience but it is, at the same time, subject to some theoretical discussion. The first edition of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006 ) differentiated between an arrogant/entitled and a depressed/depleted subtype of narcissism (Blatt, 1974 ). The PDM characterized “depleted self-imagery, angry, shameful, and depressed affects, self-criticism and suicidality, and interpersonal hypersensitivity/social withdrawal” (Morey and Stagner, 2012 , p. 910). In the PDM-2, which focuses on personality styles and not on personality disorders, entitlement is mentioned only as a pattern in adolescents with narcissism (Lingiardi and McWilliams, 2017 ).

The same applies to clinging to the belief that one is better than others and condescension toward others. These characteristics can also be seen in both expressions of narcissism, and particularly in masochistic narcissism: the grandiosity of suffering is hidden by silently and secretly experiencing the grandiosity of being able to bear any adverse events (Fairbairn, 1940 ; Kernberg, 2007 ).

Entitlement and condescension are two characteristics of narcissism that have given narcissism its negative connotation in everyday speech. In psychodynamic theory, there is a close association between the nature of entitlement and a defensive wilful resistance to dependency and reciprocity. Patients wilfully decline to relate with another in order to get what they want; instead, they expect it to be served or granted without having to ask explicitly. Asking is about losing, as asking would acknowledge neediness and dependency. Research has shown that excessive and restricted forms of relational entitlement are significantly associated with insecure attachment styles (Tolmacz and Mikulincer, 2011 ). In the clinical situation, we encounter patients who literally refuse to give up their entitlement. Their narcissistic rage is fuelled to no purpose by a feeling of entitlement and by the demand to be compensated for the misdeeds or shortcomings of persons or circumstances in the past. In our consulting room, we meet patients who cannot cut their losses with respect to situations in the past and, in their hate, remain attached to a parent in an obsessive and spiteful way. Working through this persistence is often painstakingly difficult because the rage prevents patients from establishing the psychological distance through the self-as-object that is necessary to see the insanity of their expectations.

Evaluating Personality Traits: Attention Seeking

The AMPD conceptualizes attention seeking as: “Excessive attempts to attract and be the focus of the attention of others; admiration seeking” (American Psychiatric Association, 2013 , p. 768).

Again, it is easy to associate these criteria with overt narcissism and therefore fail to notice covert attention-seeking involving putting others in the spotlight. The essence of this latter type of self-esteem regulation is that patients subconsciously see their self-effacing behavior in the service of the well-being of others as support for their self-esteem. However—and this is essential—the relationship with the other is instrumental and can therefore be perceived by the other as manipulative. In intersubjective terms: the other is treated as an object that possesses conditional value. Even when the other is placed explicitly in the spotlight and patients do not get any exposure for themselves, the self-esteem of vulnerable patients may be enhanced considerably as they attribute the other's greatness to their own contribution (Kohut's “narcissistic mirroring needs”). Vulnerable narcissism is often found in persons who claim to function best as “the second person.”

Attention seeking therefore involves not only seeking admiration for oneself directly; it also includes forms of behavior in which admiration is given to others. This is a classic pitfall in treatment when, in the transference-countertransference matrix, the patient and therapist build up a mutual admiring collusion as both being “the best ever, together.” This form of covert, “eager to please,” narcissism is well-documented in psychoanalytic literature but often underdiagnosed in clinical practice. “Eager to please” narcissism is often associated with parentification in childhood (Miller, 1981 ).

Concluding Remarks

In this article we integrated Pincus and Lukowitsky's ( 2010 ) hierarchical model of pathological narcissism, contemporary psychodynamic concepts of narcissism, and the diagnostic concept of narcissism in the AMPD.

Pincus and Lukowitsky encourage clinicians to use this hierarchical model as it opens up opportunities for shared points of interest in empirical research from different scholarly perspectives. Capacities for self-regulation and emotion regulation can, for example, be operationalized from social-learning theory and from a psychodynamic perspective, with each adding valuable knowledge. Pincus and Lukowitsky's valuable review showed there has been hardly any research into NPD with a clinical patient sample. More research involving a clinical sample is therefore needed. In addition, researchers could adapt their methods in order to conduct research that is clinically relevant for mental health care by focusing on phenomena that can be addressed in psychotherapeutic treatment. Pincus and Lukowitsky's review also showed that narcissism research is skewed by the use of the Narcissistic Personality Inventory, which mostly assesses adaptive expressions of grandiose narcissism. In the hierarchical model, vulnerable narcissism emerges as a relatively new concept for non-psychodynamically informed researchers and therapists, and additional measures have to be developed to cover this concept.

For us, one of the major advantages of the AMPD is the use of structured clinical evaluations of disturbances of the self and interpersonal functioning. In the present paper, we have discussed at length the thematic content of the AMPD. As psychodynamically oriented therapists, we are enthusiastic about the opportunities to include psychodynamic and structural concepts (see also: Bornstein, 2015 ). In addition to the thematic content, we welcome the dimensional evaluation of the severity of personality disorder pathology, as operationalized in DSM AMPD Criterion A, which can be assessed by instruments like the Semi-structured Interview for Personality Functioning (STiP-5.1) and Level of Personality Functioning Scale Self-Report (LPFS-SR) (Hutsebaut et al., 2017 ), or scorings based on the Object Relations Inventory (ORI) (Borroni et al., 2020 ).

In addition to the thematic content, we welcome the dimensional evaluation of the severity of personality disorder pathology. Kernberg's structural model for personality organization could provide an insight into the severity of all these thematic elements, in other words whether relevant psychodynamic features are organized in a neurotic or high-level/low-level borderline way. This provides the practitioner with information about the prognosis and the indication for the treatment model (Caligor and Stern, 2020 ).

We also acknowledge that there are a number of discussion points. Following the example of all psychodynamic theories, the AMPD assumes in the case of NPD that there is a disturbance that goes back to early child development. However, in all honesty, there is still no empirically derived theory for the etiology of grandiose and vulnerable narcissism, even though there is now more research with children from researchers like Brummelman et al. ( 2016 ). Relational psychodynamic theory has undeniably been supplemented with clinical child research into attachment, mentalization, emotion regulation, and parenting styles. It is, however, unfortunate that research has also shown that the link between childhood experiences and later emotional disturbances is relatively weak. More empirical data about attachment styles and emotion regulation styles in patients with narcissistic pathology would be welcome as support for the unique pattern of narcissistic relational dynamics.

In the final evaluation of the four AMPD DSM-5 elements of personality functioning, all the elements seem to have equal importance but clinical experience and psychodynamic clinical theory clearly place most emphasis on the element of identity, with self-regulation and emotion regulation as the most important aspect of this element. This problem can be resolved by further research into the relative importance of the four elements of personality dysfunction. The need to evaluate the severity of impairment in personality functioning is a valuable element in the proposed diagnostic criteria for NPD that psychodynamically oriented therapists could use to their benefit. We believe that the criteria for the two personality traits, grandiosity and attention seeking, rely too heavily on the definition of NPD in the traditional DSM-5, with its focus on grandiose narcissism. However, further research could determine whether only these two traits pertain to NPD or if other traits might be relevant as well. Future research using the Level of Personality Functioning Scale, as proposed in the AMPD, will provide ample opportunities for introducing a more sophisticated psychodynamic perspective.

The AMPD comes close to how psychoanalytic therapists could conceptualize their daily practice (see also: Caligor and Stern, 2020 ). As mentioned here, a positive aspect of the AMPD is that the diagnostic evaluation of the level of personality functioning is based on a structured clinical evaluation of four clinically relevant elements. The model addresses all the theoretical and clinical elements of pathological narcissism mentioned, such as self-regulation, affect regulation, interpersonal difficulties, grandiose/vulnerable, and covert/overt. In contrast to DSM-5 personality disorders in Section II, the AMPD clearly offers a more integrative approach. However, understandably, the basic tenet in clinical theory that distancing from the significant other forms the basis for developing NPD is not operationalized in the AMPD. Ultimately, this distancing can only be clinically inferred by assessing its consequences, which are described in the AMPD.

Now, after all this theory, the proof of the pudding is once again in the eating. In our case, the proof is to be found in the therapies we provide. Many guidelines for treating pathological narcissism have been developed in the last 10 years. Choi-Kain ( 2020 ) advocates using General Psychiatric Management, while others propose modifications of existing evidence-based treatment models for BPD to treat pathological narcissism: Mentalization-Based Treatment (Drozek and Unruh, 2020 ), Transference Focused Psychotherapy (Diamond and Hersh, 2020 ), Dialectical Behavior Therapy (Reed-Knight and Fischer, 2011 ), or Schema Focused Therapy (Young et al., 2003 ). Nevertheless, others focus on specific themes when treating pathological narcissism, for example in psychodynamic therapy (Crisp and Gabbard, 2020 ) or the client-centered Clarification-Oriented Psychotherapy (Maillard et al., 2020 ). Traditional high-frequency psychoanalysis—three to five weekly sessions on the couch—seems to have missed the boat in terms of establishing a position in the discussion.

After we concluded the draft version of this publication, the paper The “Why” and “How” of narcissism. A process model (Grapsas et al., 2020 ) came to our attention. It comes from the field of social learning and experimental psychology. Almost none of the references in that paper overlap with those in the present paper. Given the realization that there are so many overlaps, it is shocking that we seem to know so little about each other's work. For example, both fields look at internal processing in subjects with narcissism. Grapsas et al. ( 2020 ) propose a self-regulation model of grandiose narcissism that illustrates an interconnected set of processes through which narcissists pursue social status in their moment-by-moment transactions with their environments. In the same way, Ronningstam ( 2020b ) draws attention to internal processing in patients and how it contributes to narcissistic personality functioning. “Studies provide evidence for a neuropsychological core deficit in individuals with pathological narcissism or NPD, which affects their ability to access, tolerate, identify, and verbalize emotions” (Ronningstam, 2020b , p. 85). Narcissism seems to be associated with many bioneurological phenomena that are prototypical for narcissism. Experimental research has found increased sensitivity to subtle cues of non-acceptance in facial expressions, the “denial” of physical shame reactions after being devalued, the rise of cortisol levels in situations of social threat, or the activation of brain regions sensitive to pain in response to exclusion. Ronningstam argues that more attention should be paid to all kinds of internal processing from a neuropsychoanalytic point of view. As in the treatment of traumatized patients, this approach could inform the therapist in therapeutic stalemates.

Affective neuroscience can enlighten the neurological correlates of our subjective states. Solms ( 2017 ) argues that striving for homeostasis of the self pertains specifically to “basic (brainstem) consciousness, which consists in states rather than images ” (Solms, 2017 , p. 6). This is the self-system Schore calls the implicit self, associated with the unrepressed unconscious. Central to Schore's thinking is the notion that the idea of a single unitary self is misleading: “What we call the self is in reality a system of self states, that develop in the early years, but grow to more complexity during the life span” (Schore, 2017 , p. 74). In the first year of life, the structuralization of the right brain self develops in the course of the interdependent interaction between child and caretakers ( self-objects ), especially through processes of mismatch and repair in attachment, and with it (mal)adaptive implicit self-regulation processes develop. In early development, this implicit self, supposedly located in the lateralized right brain, is basically relational, as the self-states develop out of the interaction with the self-objects. Schore ( 2009 , 2017 ) locates the brain's major self-regulatory systems in the orbital prefrontal areas of the right hemisphere. Its functioning belongs to the unrepressed unconscious; its content can be felt but cannot be translated into words or symbols. Accordingly, in psychotherapy, it cannot be reached through interpretations making the unconscious conscious, but it becomes visible in enactments between psychoanalyst and patient. Somewhat later in early development, after the second year, the verbal, conscious left lateralized self-system (“left mind”) develops. Schore writes: “Despite the designation of the verbal left hemisphere as “dominant” due to its capacities for explicitly processing language functions, it is the right hemisphere and its implicit homeostatic survival and affect regulation functions that are truly dominant in human existence” (Schore, 2017 , p. 74).

The central challenge in the decade to come would seem to be to differentiate between NPD from BPD and to establish specific recommendations for treatment. Indeed, we agree with the comment made by Choi-Kain ( 2020 ) that was quoted in the introduction of this paper, that we can now look ahead to a new wave of investigation and treatment development.

Author Contributions

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors want to thank Lois Choi-Kahn for her comments on an earlier draft of this paper and Laura Muzi and Andrea Scalabrini for their helpful comments during the review process.

1 This research outcome has been reframed by us, as Tanzilli and Gualco use different subtypes of narcissism.

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• Research article
• Open access
• Published: 14 August 2020

Living with pathological narcissism: a qualitative study

• Nicholas J. S. Day 1 ,
• Michelle L. Townsend 1 &
• Brin F. S. Grenyer 1  

Borderline Personality Disorder and Emotion Dysregulation volume  7 , Article number:  19 ( 2020 ) Cite this article

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A Correction to this article was published on 22 January 2022

This article has been updated

Research into the personality trait of narcissism have advanced further understanding of the pathological concomitants of grandiosity, vulnerability and interpersonal antagonism. Recent research has established some of the interpersonal impacts on others from being in a close relationship with someone having such traits of pathological narcissism, but no qualitative studies exist. Individuals with pathological narcissism express many of their difficulties of identity and emotion regulation within the context of significant interpersonal relationships thus studying these impacts on others is warranted.

We asked the relatives of people high in narcissistic traits (indexed by scoring above a cut-off on a narcissism screening measure) to describe their relationships ( N  = 436; current romantic partners [56.2%]; former romantic partners [19.7%]; family members [21.3%]). Participants were asked to describe their relative and their interactions with them. Verbatim responses were thematically analysed.

Participants described ‘grandiosity’ in their relative: requiring admiration, showing arrogance, entitlement, envy, exploitativeness, grandiose fantasy, lack empathy, self-importance and interpersonal charm. Participants also described ‘vulnerability’ of the relative: contingent self-esteem, hypersensitivity and insecurity, affective instability, emptiness, rage, devaluation, hiding the self and victimhood. These grandiose and vulnerable characteristics were commonly reported together (69% of respondents). Participants also described perfectionistic (anankastic), vengeful (antisocial) and suspicious (paranoid) features. Instances of relatives childhood trauma, excessive religiosity and substance abuse were also described.

Conclusions

These findings lend support to the importance of assessing the whole dimension of the narcissistic personality, as well as associated personality patterns. On the findings reported here, the vulnerable aspect of pathological narcissism impacts others in an insidious way given the core deficits of feelings of emptiness and affective instability. These findings have clinical implications for diagnosis and treatment in that the initial spectrum of complaints may be misdiagnosed unless the complete picture is understood. Living with a person with pathological narcissism can be marked by experiencing a person who shows large fluctuations in affect, oscillating attitudes and contradictory needs.

Introduction

The current diagnostic description of narcissistic personality disorder (NPD) as it appears in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 5th edition, [ 1 ]) includes a lot of information about how the person affects others, such as requiring excessive admiration, having a sense of entitlement, interpersonal exploitativeness, showing both a lack of empathy for others and feeling others are envious of their perceived special powers or personality features. Despite these features being important aspects of narcissism that have been validated through empirical research [ 2 , 3 ], they have been criticised for their emphasis on grandiosity and the exclusion of vulnerability in narcissism [ 4 , 5 ], a trend that is mirrored in the field more generally and runs counter to over 35 years of clinical theory [ 3 ]. The more encompassing term ‘pathological narcissism’ has been used to better reflect personality dysfunction that is fundamentally narcissistic but allows for both grandiose and vulnerable aspects in its presentation [ 6 ].

Recognising the vulnerable dimension of narcissism has significant implications for treatment [ 7 ], including providing an accurate diagnosis and implementing appropriate technical interventions within treatment settings. Vulnerable narcissism, in marked contrast to the overt grandiose features listed in DSM-5 criteria, includes instances of depressed mood, insecurity, hypersensitivity, shame and identification with victimhood [ 8 , 9 , 10 , 11 , 12 ]. Pincus, Ansell [ 13 ] developed the Pathological Narcissism Inventory (PNI) to capture this narcissistic vulnerability in three factors. The factor ‘contingent self-esteem’ (item example: ‘It’s hard for me to feel good about myself unless I know other people like me’) reflects a need to use others in order to maintain self-esteem. The factor ‘devaluing’ includes both devaluation of others who do not provide admiration needs (‘sometimes I avoid people because I’m concerned that they’ll disappoint me’) and of the self, due to feelings of shameful dependency on others (‘when others disappoint me, I often get angry at myself’). The factor ‘hiding the self’ (‘when others get a glimpse of my needs, I feel anxious and ashamed’) reflects an unwillingness to show personal faults and needs. This factor may involve a literal physical withdrawal and isolation [ 14 ] but may also include a subtler emotional or psychic withdrawal due to feelings of inadequacy and shame which may result in the development of an imposter or inauthentic ‘false self’ [ 11 , 15 ], and which may also include a disavowal of emotions, becoming emotionally ‘empty’ or ‘cold’ [ 14 ]. Another aspect described in the literature are instances of ‘narcissistic rage’ [ 16 ] marked by hatred and envy in response to a narcissistic threat (i.e. threats to grandiose self-concept). Although commonly reported in case studies and clinical reports, it is unclear if it is a feature of only grandiose presentations or if it may more frequently present in vulnerable presentations [ 17 ].

While the differences in presentation between grandiose and vulnerable narcissism appear manifest, it has been argued that they reflect both sides of a narcissistic ‘coin’ [ 9 ] that may be regularly oscillating, inter-related and state dependent [ 6 , 18 , 19 , 20 , 21 , 22 ]. As such, it may not be as important to locate the specific presentation of an individual as to what ‘type’ they are (i.e. grandiose or vulnerable), as it is to recognise the presence of both of these aspects within the person [ 23 ]. The difficulty for these patients is the pain and distress that accompanies having such disparate ‘split off’ or unintegrated parts of the self, which result in the defensive use of maladaptive intra and interpersonal methods of maintaining a stable self-experience [ 24 ]. This defensive operation is somewhat successful, and may give the impression of a coherent and stable identity, however as noted by Caligor and Stern [ 25 ] “manifestly vulnerable narcissists retain a connection to their grandiosity … [and] even the most grandiose narcissist may have internal feelings of inadequacy or fraudulence” (p. 113).

The vulnerable dimension of narcissism, with its internal feelings of emptiness and emotion dysregulation, may reflect a more general personality pathology similar to that of borderline personality disorder (BPD) [ 26 ]. For instance, Euler, Stobi [ 27 ] found grandiose narcissism to be related to NPD, but vulnerable narcissism to be related to BPD. In a similar vein, Hörz-Sagstetter, Diamond [ 28 ] proposes grandiosity as a narcissistic ‘specific’ factor that distinguishes it from other disorders (e.g. BPD). This grandiosity, however, “ predisposes [these individuals] to respond with antagonism/hostility and reduced reality testing when the grandiose self is threatened ” (p.571). This antagonism, hostility and the resultant interpersonal dysfunction are well-documented aspects of pathological narcissism [ 29 , 30 , 31 , 32 ], that exacts a large toll on individuals in the relationship [ 33 , 34 ]. As the specific features of the disorder are perhaps therefore best evidenced within the context of these relationships, gaining the perspective of the ‘other’ in the relationship would present a unique perspective that may not be observable in other contexts (e.g. clinical or self-report research). For example, a recent study by Green and Charles [ 35 ] provided such a perspective within the context of domestic violence. They found that those in a relationship with individuals with reportedly narcissistic features described overt (e.g. verbal and physical) and covert (e.g. passive-aggressive and manipulative) expressions of abuse and that these behaviours were in response to perceived challenges to authority and to counteract fears of abandonment. As such, informant ratings may be a novel and valid methodology to assess for personality pathology [ 36 ], as documented discrepancies between self-other ratings suggest that individuals with pathological narcissism may not provide accurate self-descriptions [ 37 ]. Further, Lukowitsky and Pincus [ 38 ] report high levels of convergence for informant ratings of narcissism, indicating that multiple peers are likely to score the same individual similarly and, notably, individuals with pathological narcissism agreed with observer ratings of interpersonal dysfunction, again highlighting this aspect as central to the disorder [ 6 ]. The aim of this study is to investigate the reported characteristics of individuals with pathologically narcissistic traits from the perspective of those in a significant personal relationship with these individuals. For this research, partners and family members will be referred to as ‘participants’. Individuals with pathological narcissism will be referred to as the ‘relative’.

Recruitment

Participants were relatives of people reportedly high in narcissistic traits, and all provided written informed consent to allow their responses to be used in research, following institutional review board approval. The participants were recruited through invitations posted on various mental health websites that provide information and support that is narcissism specific (e.g. ‘Narcissistic Family Support Group’). Recruitment was advertised as being specifically in relation to a relative with narcissistic traits. A number of criteria were applied to ensure that included participants were appropriate to the research. First, participants had to identify as having a ‘significant personal relationship’ with their relative. Second, participants had to complete mandatory questions as part of the survey. Mandatory questions included basic demographic information (age, gender, relationship type) and answers to qualitative questions under investigation. Non-mandatory questions included questions such as certain demographic questions (e.g. occupation) and questions pertaining to their own support seeking. Third, the relative had to have a cumulative score of 36 (consistent with previous methodology, see [33]) or above on a narcissism screening measure (described in Measures section), as informed by participants.

Participants

A total of 2219 participants consented to participate in the survey. A conservative data screening procedure was implemented to ensure that participants were appropriate to the research. First, participants were removed who indicated that they did not have a ‘significant’ (i.e. intimate) personal relationship with someone who was narcissistic ( n  = 129). Second, participants who clicked on the link to begin the survey but dropped out within the first 1–5 questions were deemed ‘non-serious’ and were removed ( n  = 1006). Third, participants whose text sample was too brief (i.e. less than 70 words) to analyse were excluded ( n  = 399) as specified by Gottschalk, Winget [ 39 ]. Finally, participants identified as rating relatives narcissism below cut off score of 36 on a narcissism screening measure were removed ( n  = 249). Inspection of pattern of responses indicated that none of the remaining participants had filled out the survey questions inconsistently or inappropriately (e.g. scoring the same for all questions). The remaining 436 participants formed the sample reported here. Table  1 outlines the demographic information of participants and the relative included in the study.

Participants were also asked to report on the diagnosis that their relative had received. These diagnoses were specified as being delivered by a mental health professional and not the participants own speculation. The majority of participants either stated that their relative has not received a formal diagnosis, or that they did not know ( n  = 284, 65%). A total of 152 (35%) participants stated that their relative had received an official diagnosis from a mental health professional (See Table  2 ).

Pathological narcissism inventory (Carer version) (SB-PNI-CV)

Schoenleber, Roche [ 40 ] developed a short version of the Pathological Narcissism Inventory (SB-PNI; ‘super brief’) as a 12 item measure consisting of the 12 best performing items for the Grandiosity and Vulnerability composites (6 of each) of the Pathological Narcissism Inventory [ 13 ]. This measure was then adapted into a carer version (SB-PNI-CV) in the current research, consistent with previous methodology [ 33 ] by changing all self-referential terms (i.e. ‘I’) to refer to the relative (i.e. ‘my relative’). The scale operates on a Likert scale from 0 (‘not at all like my relative’) to 5 (‘very much like my relative’). By summing participant responses, a total score of 36 indicates that participants scored on average ‘a little like my relative’ to all questions, indicating the presence of pathologically narcissistic traits. The SB-PNI-CV demonstrated strong internal consistency (α = .80), using all available data ( N  = 1021). Subscales of the measure also demonstrated internal consistency for both grandiose (α = .73) and vulnerable (α = .75) items. Informant-based methods of investigating narcissism and its effects has previously been found to be effective and reliable [ 30 ] with consensus demonstrated across multiple observers [ 38 ].

Qualitative analyses

Participants who met inclusion criteria were asked to describe their relative using the Wynne-Gift speech sample procedure as outlined by Gift, Cole [ 41 ]. This methodology was developed for interpersonal analysis of the emotional atmosphere between individuals with severe mental illness and their relatives, it has also been used in the context of assessing relational functioning within marital couples [ 41 ]. For the purpose of this study, the speech sample prompt was used to elicit descriptive accounts of relational functioning, which included participants responding to the question:

‘What is your relative like, how do you get on together?’

Participants were given a textbox to respond to this question in as much detail as they would like. However, participants whose text responses were too brief (< 70 words), were removed from analysis as specified by Gottschalk, Winget [ 39 ]. It is important to note however that these participants who were removed ( n  = 399) did not differ from the included participants in any meaningful way regarding demographic information. The mean response length was 233 words (SD = 190) and text responses ranged from 70 to 1279 words.

Analysis of the data occurred in multiple stages. First, a phenomenological approach was adopted which places primacy on understanding the ‘lived experience’ of participant responses [ 42 ] whilst ‘bracketing’ researcher preconceptions. This involved reading and re-reading all participant responses in order to be immersed in the participants subjective world, highlighting text passages regarding the phenomenon under examination (i.e. personality features, descriptions of behaviour, etc) and noting comments and personal reactions to the text in the margins. This is done in an attempt to make the researchers preconceptions explicit, in order to attend as close as possible as to the content of what is being said by the participant. Second, codebook thematic analysis was used for data analysis as outlined by Braun, Clarke [ 43 ], which combines ‘top down’ and ‘bottom up’ approaches. Using this approach, a theory driven or ‘top down’ perspective was taken [ 44 ] in which researchers attempted to understand the reality of participants through their expressed content and within the context of the broader known features informed by the extensive prior work on the topic. In this way, the overarching themes of ‘grandiosity’ and ‘vulnerability’ were influenced by empirically determined features within the research literature (e.g. DSM-5 diagnostic criteria, factors within the PNI), however themes and nodes were free to be ‘split’ or merged organically during the coding process reflecting the ongoing conceptualisation of the data by the researchers. Significant statements were extracted and coded into nodes reflecting their content (e.g. ‘narcissistic rage’, ‘entitlement’) using Nvivo 11. This methodology of data analysis via phenomenologically analysing and grouping themes is a well-documented and regularly utilized qualitative approach (e.g. [ 45 , 46 ]). Once data analysis had been completed the second author completed coding for inter-rater reliability analysis on 10% of data. The second rater was included early in the coding process and the two reviewers meet on several occasions to discuss the nodes that were included and those that were emerging from the data. 10% of the data was randomly selected by participant ID numbers. At the end of this process, it was then confirmed that the representation of the data also reflected the participant relationships (i.e. marital partner, child etc). Cohen’s Kappa coefficient was used to index inter-rater reliability by calculating the similarity of nodes identified by the two researchers. This method takes into consideration the agreement between the researchers (observed agreement) and compares it to how much agreement would be expected by chance alone (chance agreement). Inter-rater reliability for the whole dataset was calculated as κ = 0.81 which reflects a very high level of agreement between researchers that is not due to chance alone [ 47 ].

Cluster analysis

A cluster analysis dendrogram was generated using Nvivo 11 for purposes of visualisation and to explore the underlying dimensions of the data [ 48 ]. This dendrogram displays the measure of similarity between nodes as coded, in which each source (i.e. participant response) is coded by each node. If the source is coded by the node it is listed as ‘1’ and ‘0’ if it is not. Jaccard’s coefficient was used to calculate a similarity index between each pair of items and these items were grouped into clusters using the complete linkage hierarchical clustering algorithm [ 49 ].

Two broad overarching dimensions were identified. The first dimension, titled ‘grandiosity’, included descriptions that were related to an actual or desired view of the self that was unrealistically affirmative, strong or superior. The second dimensions, titled ‘vulnerability’, included an actual or feared view of the self that was weak, empty or insecure. Beyond these two overarching dimensions, salient personality features not accounted for by the ‘grandiose’ or ‘vulnerable’ dimensions were included within a category reflecting ‘other personality features’. Themes not relating specifically to personality style, but that may provide insights regarding character formation or expression were included within the category of ‘descriptive themes’.

A total of 1098 node expressions were coded from participant responses ( n  = 436), with a total of 2182 references. This means participant responses were coded with an average of two to three individual node expressions (e.g. ‘hiding the self’, ‘entitlement’) and there were on average 5 expressions of each node(s) in the text.

Overarching dimension #1: grandiosity

Participants described the characterological grandiosity of their relative. This theme was made up of ten nodes: ‘Requiring Admiration’, ‘Arrogance’, ‘Entitlement’, ‘Envy’, ‘Exploitation’, ‘Grandiose Fantasy’, ‘Grandiose Self Importance’, ‘Lack of Empathy’, ‘Belief in own Specialness’ and ‘Charming’.

Node #1: requiring admiration or attention seeking

Participants described their relative as requiring excessive admiration. For instance, “He puts on a show for people who can feed his self-image. Constantly seeking praise and accolades for any good thing he does” (#1256); “He needs constant and complete attention and needs to be in charge of everything even though he expects everyone else to do all the work” (#1303).

Node #2: arrogance

Relatives were described as often displaying arrogant or haughty behaviours or attitudes. For instance, “ He appears to not be concerned what other people think, as though he is just ‘right’ and ‘superior’ about everything” (#1476) and “My mother is very critical towards everyone around her... family, friends, neighbours, total strangers passing by... everybody is ‘stupid’” (#2126).

Node #3: entitlement

Relatives were also described as having a sense of entitlement. For example, “I paid all of the bills. He spent his on partying, then tried to tell me what to do with my money. He took my bank card, without permission, constantly. Said he was entitled to it” (#1787) and “He won’t pay taxes because he thinks they are a sham and he shouldn’t have to just because other people pay” (#380).

Node #4: envy and jealousy

Participants described instances of their relative being envious or jealous of others. Jealousy, being in relation to the threatened loss of important relationships, was described by participants. For instance, after describing the abusive behaviours of their relative one participant stated “It got worse after our first son was born, because he was no longer the centre of my attention. I actually think he was jealous of the bond that my son and I had” (#1419). Other participants, despite using the term ‘jealous’, described more envious feelings in their relative relating to anger in response to recognising desirable qualities or possessions of others. For instance, another participant stated “[they have] resentment for people who are happy, seeing anyone happy or doing great things with their life makes them jealous and angry” (#1744). Some participants described their relative believing that others are envious of them, for example “ [ he] thought everyone was jealous he had money and good looks.” (#979) and “[he] tried to convince everyone that people were just jealous of him because he had a nice truck” (#1149).

Node #5 exploitation

Relatives were described as being interpersonally exploitative (i.e. taking advantage of others). For instance, one participant stated “He brags how much he knows and will take someone else’s knowledge and say he knew that or claim it’s his idea” (#1293). Another participant stated “ With two other siblings that are disabled, she uses funding for their disabilities to her advantage … I do not think she cares much for their quality of life, or she would use those funds for its intended use.” (#998).

Node #6 grandiose fantasy

Participants also described their relatives as engaging in unrealistic fantasies of success, power and brilliance. For instance, the response “He believes that he will become a famous film screen writer and producer although he has no education in film” (#1002); “He was extremely protective of me, jealous and woefully insecure. [He] went on ‘missions’ where he was sure [world war three] was about to start and he was going to save us, he really believes this” (#1230).

Node #7 grandiose self importance

Relatives were described as having a grandiose sense of self-importance (e.g. exaggerating achievements, expecting to be recognised as superior without commensurate achievements). Examples of this include “He thinks he knows everything … conversations turn into an opportunity for him to ‘educate’ me” (#1046); “ He tells endless lies and elaborate stories about his past and the things he has achieved, anyone who points out inconsistencies in his stories is cut out of his lif e” (#178).

Node #8 compromised empathic ability

Participants described their relatives as being unwilling to empathise with the feelings or perspectives of others. Some examples include “she has never once apologized for her abuse, and she acts as if it never happened. I have no idea how she can compartmentalize like that. There is no remorse” (#1099) and “[he] is incapable of caring for all the needs of his children because he cannot think beyond his own needs and wants, to the point of his neglect [resulting in] harm to the children” (#1488).

Node #9 belief in own specialness

Relatives were described as believing they were somehow ‘special’ and unique. For example, one participant described their relative as fixated with their status as an “important [member] of the community” (#860), another participant stated “he considers himself a cut above everyone and everything... Anyone who doesn’t see him as exceptional will suffer” (#449). Other responses indicated their relatives were preoccupied with being associated with other high status or ‘special’ people. For instance, one participant stated that their relative “likes to brag about how she knows wealthy people as if that makes her a better person” (#318) and another stating that their relative “loves to name drop” (#49).

Node #10 charming

Participants also described their relative in various positive ways which reflected their relatives’ likeability or charm. For instance, “He is fun-loving and generous in public. He is charming and highly intelligent” (#1401); “His public persona, and even with extended family, is very outgoing, funny and helpful. Was beloved by [others]” (#1046) and “He is very intelligent and driven, a highly successful individual. Very social and personable and charming in public, funny, the life of the party” (#1800).

Overarching dimension #2: vulnerability

Participants described the characterological vulnerability of their relative. This theme was made up of nine nodes: ‘Contingent Self Esteem’, ‘Devaluing’, ‘Emotionally Empty or Cold’, ‘Hiding the Self’, ‘Hypersensitive’, ‘Insecurity’, ‘Rage’, ‘Affective Instability’ and ‘Victim Mentality’.

Node #1 contingent self esteem

Participants described their relatives as being reliant on others approval in order to determine their self-worth. For instance, “She only ever seems to be ‘up’ when things are going well or if the attention is on her” (#1196) and “He appears to be very confident, but must have compliments and reassuring statements and what not, several times a day” (#1910).

Node #2 devaluing

Relatives were described as ‘putting down’ or devaluing others in various ways and generally displaying dismissive or aggressive behaviours. For instance, “On more than one occasion, he’s told me that I’m a worthless person and I should kill myself because nobody would care” (#1078) and “He feels intellectually superior to everyone and is constantly calling people idiotic, moron, whatever the insult of the day is” (#1681).

Relatives were also described as reacting to interpersonal disappointment with shame and self-recrimination, devaluing the self. For instance, “They are extremely [grandiose] … [but] when someone has the confidence to stand up against them they crumble into a sobbing mess wondering why it’s always their fault” (#1744) and “I have recently started to stand up for myself a little more at which point he will then start saying all the bad things are his fault and begging forgiveness” (#274).

Node #3 emotionally empty or cold

Participants described regularly having difficulty ‘connecting’ emotionally with their relative. For instance, one participant described that their relative was “largely sexually disengaged, unable to connect, difficulty with eye contact … he used to speak of feeling dead” (#1365); another stated “he was void of just any emotion. There was nothing. In a situation of distress he just never had any feeling. He was totally void of any warmth or feeling” (#323), another stated “I gave him everything. It was like pouring myself into an emotional black hole” (#627).

Node #4 hiding the self

Participants reported instances in which their relative would not allow themselves to be ‘seen’, either psychologically or physically. One way in which they described this was through the construction of a ‘false self’. For instance “He comes across very confident yet is very childish and insecure but covers his insecurities with bullish and intimidating behaviour” (#2109). Another way participants described this hiding of self was through a literal physical withdrawal and isolation. For example, “He will also have episodes of deep depression where he shuts himself off from human contact. He will hide in his room or disappear in his sleeper semi-truck for days with no regard for his family or employer” (#1458).

Node #5 hypersensitive

Participants reported feeling as though they were ‘walking on eggshells’ as their relative would respond volatilely to perceived attacks. For instance, “She cannot take advice or criticism from others and becomes very defensive and abusive if challenged” (#1485); “It was an endless mine field of eggshells. A word, an expression would be taken against me” (#532) and “Very irrational and volatile. Anything can set her off on a rage especially if she doesn’t get her way” (#822).

Node #6 insecurity

Relatives were described as having an underlying sense of insecurity or vulnerability. For instance “He really is just a scared little kid inside of a big strong man’s body. He got stuck when he was a child” (#1481); “At the core he feels unworthy, like a fake and so pretty much all introspection and self-growth is avoided at all costs” (#532) and “At night when the business clothes come off his fears eat him up and he would feel highly vulnerable and needs lots of reassurance” (#699).

Node #7 rage

Participants reported that their relatives were particularly prone to displaying explosive bouts of uncontrolled rage. For example, “He has a very fragile ego … he will fly off the handle and subject his target to hours of screaming, insults and tantrum-throwing” (#1078); “he has a temper tantrum-like rage that is frightening and dangerous” (#1476); “He has hit me once. Left bruises on upper arms and back. He goes into rage and has hit walls, hits himself” (#1637).

Node #8 affective instability (symptom patterns)

Relatives were also described as displaying affective instability which may be related to anxiety and depressive disorders. Relatives were commonly described as being ‘anxious’ (#1091) including instances of hypochondria (#1525), agoraphobia (#756), panic (#699) and obsessive compulsive disorder (#2125). Relatives were also commonly described as having episodes of ‘depression’ (#1106) and depressive symptoms such as low mood (#1931), problems sleeping (#1372). Some participants also described their relative as highly suicidal, with suicidality being linked to relationship breakdowns or threats to self-image. For example, “When I state I can’t take any more or say we can’t be together … he threatens to kill himself” (#1798); “If he feels he is being criticised or blamed for something (real or imagined) … his attacks become self-destructive” (#1800).

Node #9 victim mentality

Participants reported that their relatives often described feeling as though they were the victim of attacks from others or taken advantage of in some way. For instance, “He seems to think that he has been ‘hard done by’ because after all he does for everyone, they don’t appreciate him as much as they should” (#1476); “He will fabricate or twist things that are said so that he is either the hero or the victim in a situation” (#447).

Other personality features

Participants also reported some descriptions of their relative that were not described within prior conceptualisations of narcissism. This theme was made up of 3 nodes: ‘Perfectionism’, ‘Vengeful’ and ‘Suspicious’.

Node #1 perfectionism

Participants repeatedly described their relative displaying perfectionistic or unrelenting high standards for others. For instance, “I cannot just do anything at home everything I do is not to her standard and perfection ” (#1586) and “Everything has to be done her way or it’s wrong and she will put you down. She has complete control over everything” (#1101).

Node #2 vengeful

Participants described their relative as being highly motivated by revenge and displaying vindictive punishing behaviours against others. Examples include, “[He] has expressed thoughts of wanting to hurt those who cause him problems” (#230); “He is degrading to and about anyone who doesn’t agree with him and he is very vengeful to those who refuse to conform to his desires” (#600) and “Once someone crosses him or he doesn’t get his way, he becomes vindictive and will destroy their life and property and may become physically abusive” (#707).

Node #3 suspicious

Participants described their relative as holding paranoid or suspicious beliefs about others intentions or behaviours. For instance, “He would start fights in public places with people because he would claim they were ‘looking at him and mimicking him’” (#1149) and “She is angry most days, obsessively talking about who wronged her in the past, currently or who probably will in the future” (#2116).

Descriptive themes

Several salient descriptive themes were also coded from the data that, while not relating directly to the relatives character, may provide peripheral or contextual information.

Descriptive theme #1: trauma

A number of participants described their relative as having experienced a traumatic or troubled childhood. One participant stated that their relatives’ father “was extraordinarily abusive both emotionally and physically to both him and the mother … [the father] pushed [the relative] as a young boy on prostitutes as a 12th birthday gift … He was beaten on and off from age 6 to 15 when he got tall enough to threaten back” (#1249). Another participant described the emotional upbringing of their relative “[his mother was] prone to being easily offended, fighting with him and cutting off all contact except to tell him what a rotten son he was, for months, then suddenly talking again to him as if nothing had ever happened. His father, he said, was strict and expected a lot of him. Both rarely praised him; whenever he accomplished something they would just demand better instead of congratulating him on his accomplishment” (#1909). Another participant reflected on how their relative’s upbringing may be related to their current emotional functioning, “personally I think he is so wounded (emotional, physical abuse and neglect) that he had to detach from himself and others so much just to survive” (#1640).

Descriptive theme #2: excessive religiosity

While participant’s comments on their relative’s religiosity were common, the content was varied. Some participants described their relative using religion as a mechanism to control, for instance “he uses religion in an extremely malignant way. Manipulating verses and religious sayings and interpret them according to his own will” (#132) and “very religious. She uses scripture to manipulate people into doing what she wants on a regular basis” (#1700). One participant described how their relative’s religiosity became infused with their grandiose fantasy “He has also gone completely sideways into fundamental religious doctrine, as if he knows more than the average ‘Christian’ about End Times, and all kinds of illuminati type conspiracy around that topic. He says God talks to him directly and tells him things and that he has had dead people talk to him” (#1476). Other participants described how their relative’s religiosity was merely an aspect of their ‘false self’, for example “she has a wonderful, loving, spiritual facade that she shows to the world” (#1073).

Descriptive theme #3: substance use

Participants regularly described their relative as engaging in substance use. Substances most frequently named were alcohol, marijuana, cocaine and ‘pills’. Participants reported that when their relative was using substances their behaviour often became dangerous, usually through drink driving, one participant stated “too much alcohol … he would drive back to [his work] … I was always afraid of [a driving accident]” (#76).

Subtype expression

Of 436 participants, a total of 348 unique grandiose node expressions were present and a total of 374 unique vulnerable node expressions were present. Of these, 301 participants included both grandiose and vulnerable descriptions of their relative (69% of sample). Only 47 (11% of sample) focused on grandiose features in their description of their relative, and only 88 participants (20% of sample) focused on vulnerable features.

A cluster analysis dendrogram was generated using Nvivo 11 for purposes of visualising and exploring the underlying dimensions of the data [ 48 ] and is displayed in Fig.  1 . Four clusters of nodes and one standalone node can be distinguished. The first cluster, labelled ‘Fantasy Proneness’, includes nodes reflecting the predominance of ‘fantasy’ colouring an individuals interactions, either intrapersonally (‘grandiose self-importance, belief in specialness’) or interpersonally (‘suspicious, envy’). The second cluster, labelled ‘Negative Other’, reflects nodes concerned with a detached connection with others (‘emotionally empty’) and fostering ‘vengeful’ and ‘exploitative’ drives towards others, as well as feelings of victimhood. Interestingly, despite being related to these other aspects of narcissism, ‘perfectionism’ was factored as reflecting its own cluster, labelled ‘Controlling’. The fourth cluster, labelled ‘Fragile Self’, includes nodes indicating feelings of vulnerability (‘affective instability’, ‘insecurity’) and shameful avoidance (‘hiding the self’, ‘false self’, ‘withdrawal’) due to these painful states. The fifth cluster, labelled ‘Grandiose’ reflects a need (‘contingent self-esteem’, ‘requiring admiration’) or expectation (‘entitlement’, ‘arrogance’) of receiving a certain level of treatment from others. It also includes nodes regarding how individuals foster this treatment (‘charming’, ‘rage’, and ‘devaluing’) and a hypervigilance for if their expectations are being met (‘hypersensitive’).

Cluster analysis of nodes based on coding similarity. Note. Clusters are labelled as follows: 1. Fantasy Proneness, 2. Negative Other, 3. Controlling, 4. Fragile Self, 5. Grandiose

This study aimed to qualitatively describe the interpersonal features of individuals with traits of pathological narcissism from the perspective of those in a close relationship with them.

Grandiose narcissism

We found many grandiose features that have been validated through empirical research [ 2 , 3 , 19 ]. Grandiosity, as reflected in the DSM-5, has been argued to be a key feature of pathological narcissism that distinguishes it from other disorders [ 26 , 28 ]. One feature regularly endorsed by participants that is not encompassed in DSM-5 criteria is relatives’ level of interpersonal charm and likability. This charm as described by participants appears more adaptive than a ‘superficial charm’ that might be more exclusively ‘interpersonally exploitative’ in nature. However, it should be noted that this charm did not appear to persist, and was most often described as occurring mainly in the initial stages of a relationship or under specific circumstances (e.g. in public with an audience).

Vulnerable narcissism

We also found participants described their relative in ways consistent with the vulnerable dimensions of the pathological narcissism inventory (i.e. hiding the self, contingent self esteem and devaluing [ 50 ];). Dimensions that are also included in other popular measures for vulnerable narcissism were also endorsed by participants in our sample. For instance, the nodes of ‘hypersensitivity’, ‘insecurity’ and ‘affective instability’ reflect dimensions covered in the Hypersensitive Narcissism Scale [ 51 ] and neuroticism within the Five Factor Narcissism Inventory [ 52 ]. These aspects of narcissism have also been documented within published literature [ 12 , 27 , 53 , 54 ].

Subtype expression: cluster analysis

Most participants (69% of sample) described both grandiose and vulnerable characteristics in their relative, which given the relatively small amount of text and node expressions provided per participant is particularly salient. Given the nature of the relationship types typically endorsed by participants (i.e. romantic partner, family member), it suggests that the degree of observational data on their relative is quite high. As such, these results support the notion that an individual’s narcissism presentation may fluctuate over time [ 20 , 21 ] and that vulnerable and grandiose presentations are inter-related and oscillating [ 9 , 19 ].

The cluster analysis indicates the degree to which salient co-occurring features were coded. These features can be grouped to resemble narcissistic subtypes as described in research literature, such as the subtypes outlined by Russ, Shedler [ 55 ] in their Q-Factor Analysis of SWAP-II Descriptions of Patients with Narcissistic Personality Disorder. Our clusters #1–3 (‘Fantasy Proneness’, ‘Negative Other’ and ‘Controlling’) appear to resemble the ‘Grandiose/malignant narcissist’ subtype as described by the authors. This subtype includes instances of self-importance, entitlement, lack of empathy, feelings of victimisation, exploitativeness, a tendency to be controlling and grudge holding. Our cluster #4–5 (‘Fragile Self’ and ‘Grandiose’) appear to resemble the ‘Fragile narcissist’ subtype described including instances of depressed mood, internal emptiness, lack of relationships, entitlement, anger or hostility towards others and hypersensitivity towards criticism. Finally, our ‘Grandiose’ cluster (#5) showed overlap with the ‘high functioning/exhibitionistic narcissist’ subtype, which displays entitled self-importance but also a significant degree of interpersonal effectiveness. We found descriptions of the relative showing ‘entitlement’, being ‘charming’ and ‘requiring admiration’.

While co-occurring grandiose and vulnerable features are described at all levels of clusters in our sample, distinctions between the observed clusters may be best understood as variations in level of functioning, insight and adaptiveness of defences. As such, pathological narcissism has been understood as a characterological way of understanding the self and others in which feelings of vulnerability are defended against through grandiosity [ 56 ], and threats to grandiosity trigger dysregulating and disintegrating feelings of vulnerability [ 53 ]. Recent research supports this defensive function of grandiosity, with Kaufman, Weiss [ 11 ] stating “ grandiose narcissism was less consistently and strongly related to psychopathology … and even showed positive correlations with adaptive coping, life satisfaction and image-distorting defense mechanisms ” (p. 18). Similarly, Hörz-Sagstetter, Diamond [ 28 ] state ‘high levels of grandiosity may have a stabilizing function’ on psychopathology (p. 569). This defence, however, comes at a high cost, whether it be to the self when the defensive grandiosity fails (triggering disintegrating bouts of vulnerability) or to others, as this style of relating exacts a high toll on those in interpersonal relationships [ 33 ].

Participants described their relative as highly perfectionistic, however the perfectionism described was less anxiously self-critical and more ‘other oriented’. This style of other oriented ‘narcissistic perfectionism’ has been documented by others [ 57 ] and appears not to have the hallmarks of overt shameful self-criticism at a surface level, however may still exist in covert form [ 58 ]. Regarding the ‘vengeful’ node, Kernberg [ 16 ], Kernberg [ 59 ] describes that as a result of a pain-rage-hatred cycle, justification of revenge against the frustrating object is an almost unavoidable consequence. Extreme expressions of acting out these “ego-syntonic” revenge fantasies may also highlight the presence of an extreme form of pathological narcissism in this sample – malignant narcissism, which involves the presence of a narcissistic personality with prominent paranoia and antisocial features [ 60 ]. Lastly, Joiner, Petty [ 61 ] report that depressive symptoms in narcissistic personalities may evoke paranoid attitudes, which may in turn be demonstrated in the behaviours and attitudes expressed in the ‘suspicious’ node we found.

While this study focused on a narcissistic presentation, the presence in this sample of these other personality features (which could alternatively be described as ‘anankastic’, ‘antisocial’ and ‘paranoid’) is informed by the current conversation regarding dimensional versus categorical approaches [ 62 , 63 ]. Personality dysfunction from a dimensional perspective, such as in the ‘borderline personality organisation’ [ 23 ] or borderline ‘pattern’ [ 64 ] could understand these co-occurring personality features as not necessarily aspects of narcissism or ‘co-morbidities’, but as an individual’s varied pattern of responding that exists alongside their more narcissistic functioning, reflecting a more general level of disorganisation that resists categorisation. This is particularly reflected in Table 2 as participants reported a wide variety of diagnosed conditions, as well as the ‘Affective Instability’ node which may reflect various diagnostic symptom patterns.

Descriptive features

The relationship between trauma and narcissism has been documented [ 58 , 65 , 66 , 67 ] and the term ‘trauma-associated narcissistic symptoms’ has been proposed to identify such features [ 68 ]. Interestingly, while participants in our sample did describe instances of overt abuse which were traumatic to their relative (e.g. physical, verbal, sexual), participants also described hostile environments in which maltreatment was emotionally abusive or manipulative in nature, as well as situations where there was no overt traumatic abuse present but which most closely resemble ‘traumatic empathic failures’. This type of attachment trauma, stemming from emotionally invalidating environments, is central to Kohut’s theory of narcissistic development [ 69 , 70 ], and has found support in recent research [ 71 ]. Relatives religiosity was noteworthy, not necessarily due to its presence, but due to the narcissistic function that the religiosity served. Research on narcissism and religious spirituality has steadily accumulated over the years (for a review see: [ 72 ]) and the term ‘spiritual bypassing’ [ 73 ] is used for individuals who use religion in the service of a narcissistic defence. In our sample this occurred via alignment with an ‘ultimate authority’ in order to bolter esteem and control needs. It may be that the construction of a ‘false self’ rooted in spirituality is conferred by the praise and audience of a community of believers. Finally, participants reported their relative as engaging in various forms of substance use, consistent with prevalence data indicating high co-occurrence of narcissism and substance use [ 65 ]. While the motivation behind relatives substance use was not mentioned by participants, it is consistent with relatives more general use of reality distorting defences, albeit a more physicalised as opposed to an intrapsychic method.

Implications of findings

First, this study extends and supports the widespread acknowledged limitation of DSM-5 criteria for narcissistic personality disorder regarding the exclusion of vulnerable features (for a review of changes to dignostic criteria over time, see [ 74 , 75 ]) and we acknowledge the current discussion regarding therapist decision to provide a diagnosis of NPD [ 76 ]. However, the proliferation of alternate diagnostic labels may inform conceptualisations which do not account for the full panorama of an individual’s identity [ 7 ], adding to the already contradictory and unintegrated self-experience for individuals with a narcissistic personality. This may also impede the treatment process by informing technical interventions which may be contra-indicated. For instance, treatment of individuals with depressive disorders require different approaches than individuals with a vulnerably narcissistic presentation [ 24 , 77 ]. As such, a focus of treatment would include the integration of these disparate self-experiences, through the exploration of an individual’s affect, identity and relationships, consistent with the treatment of personality disorders more generally. Specifically, when working with an individual with a narcissistic personality, this may involve identifying and clarifying instances of intense affect, such as aggression and envy, themes of grandiosity and vulnerability in the self-concept, and patterns of idealization and devaluation in the wider relationships. The clinician will need to clarify, confront or interpret to these themes and patterns, their contradictory nature as extreme polarities, and attend to the oscillation or role reversals as they appear [ 78 ]. Second, as the characterological themes identified in this paper emerged within the context of interpersonal relationships, this highlights the interconnection between impaired self and other functioning. As such, in the context of treating an individual with pathological narcissism, discussing their interpersonal relationships may be a meaningful avenue for exploring their related difficulties with identity and emotion regulation that may otherwise be difficult to access. This is particularly salient as treatment dropout is particularly high for individuals with pathological narcissism [ 4 ], and as typical reason for attending treatment is for interpersonal difficulties [ 79 ]. Third, treatment for individuals with narcissistic personalities can inspire intense countertransference responses in clinicians [ 80 ] and often result in stigmatisation [ 81 ]. As such, these findings also provide a meaningful way for the clinician to extend empathy to these clients as they reflect on the defensive nature of the grandiose presentation, the distressing internal emptiness and insecurity for these individuals, and the potential childhood environment of emotional, sexual or physical trauma and neglect which may have informed this defensive self-organisation. Finally, these findings would also directly apply to clinicians and couples counsellors working with individuals who identify their relative as having significant narcissistic traits, providing them with a way to understand the common ways these difficulties express themselves in their relationships and the impact they may have on the individuals in the relationship. Practically, these findings may inform a heightened need for treating clinicians to assess for interpersonal violence and the safety of clients in a context of potential affective dysregulation and intense aggression. Regarding technical interventions, if working with only one of the individuals in the relationship, these findings may provide avenues for psychoeducation regarding their relatives difficulties with identity and affect regulation, helping them understand the observed oscillating and contradictory self-states of their relative. If working with both individuals or the couple, the treating clinician will need to be able to identify and interpret changes in affect and identity, and the way this manifest in the relationship functioning of the couple and their characteristic ways of responding to each other (e.g. patterns of idealization and devaluation). This may also involve attending to the ways in which the therapist may be drawn into the relationship with the couple, noticing and interpreting efforts at triangulation or any pressure to ‘pick sides’ from either individual.

Limitations

The sample selection procedure may have led to results only being true for some, but not all people living with a relative with narcissistic features. Participants were recruited online limiting the opportunity to understand participant motivation. Second, relying on informant ratings of narcissism for both screening and qualitative analysis is a limitation as we are less unable to control for severity, specificity or accuracy of participant reporting. Further, it is possible that the use of a narcissism screening tool primed participants to artificially report on particular aspects of their relative. However, the risk of biasing or priming participants is a limitation of all studies of this kind, as studies implementing informant methodology for assessing narcissism typically rely on providing participants with a set of diagnostic criteria or narcissism specific measures as their sole indicator of narcissism (e.g. [ 30 , 38 ]). As such, notwithstanding the limitations outlined, this informs the novelty and potential utility of the present approach which relies on identifying narcissism specific features amongst a backdrop of descriptions of more general functioning within intimate relationships. Third, gender disparity in participants and relatives was substantial. However, as NPD is diagnosed more commonly in males (50–75%, American Psychiatric Association, 2013) and as most participants in our sample were in a romantic, heterosexual relationship, this disparity may reflect a representative NPD sample and should not significantly affect the validity of results. Rather, this disparity may strengthen the argument that individuals with a diagnosis of NPD (as specified by DSM-5 criteria) may have co-occurring vulnerable features, which may not be currently reflected in diagnostic categories. Finally, as a result of relying on informant ratings and not assessing narcissistic individuals via structured clinical interview, questions regarding the specificity and severity of the narcissistic sample are unable to be separated in the analysis. We thus probably studied those ranging from ‘adaptive’ or high functioning narcissism [ 82 ] to more severe and disabling character disorders. Whilst we screened for narcissistic features, it was clear the sample studied also reported a broad range of other co-occurring problems.

We investigated the characteristics of individuals with pathologically narcissistic traits from the perspective of those in a significant personal relationship with them. The overarching theme of ‘Grandiosity’ involved participants describing their relative as requiring admiration, displaying arrogant, entitled, envious and exploitative behaviours, engaging in grandiose fantasy, lacking in empathy, having a grandiose sense of self-importance, believing in own sense of ‘specialness’ and being interpersonally charming. The overarching theme of ‘Vulnerability’ involved participants describing their relative’s self-esteem being contingent on others, as being hypersensitive, insecure, displaying affective instability, feelings of emptiness and rage, devaluing self and others, hiding the self through various means and viewing the self as a victim. Relatives were also described as displaying perfectionistic, vengeful and suspicious personality features. Finally, participants also described several descriptive themes, these included the relative having a trauma history, religiosity in the relative and the relative engaging in substance use. The vulnerability themes point to the problems in the relatives sense of self, whilst the grandiose themes show how these express themselves interpersonally. The complexity of interpersonal dysfunction displayed here also points to the importance of assessing all personality traits more broadly.

Availability of data and materials

The datasets generated during and/or analysed during the current study are not publicly available due to the sensitive and personal nature of participant responses but are available from the corresponding author on reasonable request.

Change history

22 january 2022.

A Correction to this paper has been published: https://doi.org/10.1186/s40479-022-00177-x

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ND has received a scholarship relating to this project. Project Air Strategy acknowledges the support of the NSW Ministry of Health.

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Day, N.J.S., Townsend, M.L. & Grenyer, B.F.S. Living with pathological narcissism: a qualitative study. bord personal disord emot dysregul 7 , 19 (2020). https://doi.org/10.1186/s40479-020-00132-8

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Narcissism Driven by Insecurity, Not Grandiose Sense of Self, New Psychology Research Shows

Narcissism is driven by insecurity, and not an inflated sense of self, finds a new study, which offers a more detailed understanding of this long-examined phenomenon and may also explain what motivates the self-focused nature of social media activity.

Narcissism is driven by insecurity, and not an inflated sense of self, finds a new study by a team of psychology researchers. Its research, which offers a more detailed understanding of this long-examined phenomenon, may also explain what motivates the self-focused nature of social media activity.

“For a long time, it was unclear why narcissists engage in unpleasant behaviors, such as self-congratulation, as it actually makes others think less of them,” explains Pascal Wallisch, a clinical associate professor in both New York University’s Department of Psychology and Center for Data Science and the senior author of the paper , which appears in the journal Personality and Individual Differences . “This has become quite prevalent in the age of social media—a behavior that’s been coined ‘flexing’.  

“Our work reveals that these narcissists are not grandiose, but rather insecure, and this is how they seem to cope with their insecurities.”

“More specifically, the results suggest that narcissism is better understood as a compensatory adaptation to overcome and cover up low self-worth,” adds Mary Kowalchyk, the paper’s lead author and an NYU graduate student at the time of the study. “Narcissists are insecure, and they cope with these insecurities by flexing. This makes others like them less in the long run, thus further aggravating their insecurities, which then leads to a vicious cycle of flexing behaviors.”

The survey’s nearly 300 participants—approximately 60 percent female and 40 percent male—had a median age of 20 and answered 151 questions via computer.

The researchers examined Narcissistic Personality Disorder (NPD), conceptualized as excessive self-love and consisting of two subtypes, known as grandiose and vulnerable narcissism. A related affliction, psychopathy, is also characterized by a grandiose sense of self. They sought to refine the understanding of how these conditions relate. 

To do so, they designed a novel measure, called PRISN ( P erformative R efinement to soothe I nsecurities about S ophisticatio N ), which produced FLEX (per F ormative se L f- E levation inde X ). FLEX captures insecurity-driven self-conceptualizations that are manifested as impression management, leading to self-elevating tendencies. 

The PRISN scale includes commonly used measures to investigate social desirability (“No matter who I am talking to I am a good listener”), self-esteem (“On the whole, I am satisfied with myself”), and psychopathy (“I tend to lack remorse”). FLEX was shown to be made up of four components: impression management (“I am likely to show off if I get the chance”), the need for social validation (“It matters that I am seen at important events''), self-elevation (“I have exquisite taste”), and social dominance (“I like knowing more than other people”). 

Overall, the results showed high correlations between FLEX and narcissism—but not with psychopathy. For example, the need for social validation (a FLEX metric) correlated with the reported tendency to engage in performative self-elevation (a characteristic of vulnerable narcissism). By contrast, measures of psychopathy, such as elevated levels of self-esteem, showed low correlation levels with vulnerable narcissism, implying a lack of insecurity. These findings suggest that genuine narcissists are insecure and are best described by the vulnerable narcissism subtype, whereas grandiose narcissism might be better understood as a manifestation of psychopathy.           

The paper’s other authors were Helena Palmieri, an NYU psychology doctoral student at the time of the study, and Elena Conte, an NYU psychology undergraduate student. 

DOI: 10.1016/j.paid.2021.110780

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A Cognitive-Behavioral Formulation of Narcissistic Self-Esteem Dysregulation

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A CBT Formulation of Narcissistic Self-Esteem Dysregulation

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• Narcissistic personality disorder

Narcissistic personality disorder is a mental health condition in which people have an unreasonably high sense of their own importance. They need and seek too much attention and want people to admire them. People with this disorder may lack the ability to understand or care about the feelings of others. But behind this mask of extreme confidence, they are not sure of their self-worth and are easily upset by the slightest criticism.

A narcissistic personality disorder causes problems in many areas of life, such as relationships, work, school or financial matters. People with narcissistic personality disorder may be generally unhappy and disappointed when they're not given the special favors or admiration that they believe they deserve. They may find their relationships troubled and unfulfilling, and other people may not enjoy being around them.

Treatment for narcissistic personality disorder centers around talk therapy, also called psychotherapy.

Narcissistic personality disorder affects more males than females, and it often begins in the teens or early adulthood. Some children may show traits of narcissism, but this is often typical for their age and doesn't mean they'll go on to develop narcissistic personality disorder.

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Symptoms of narcissistic personality disorder and how severe they are can vary. People with the disorder can:

• Have an unreasonably high sense of self-importance and require constant, excessive admiration.
• Feel that they deserve privileges and special treatment.
• Expect to be recognized as superior even without achievements.
• Make achievements and talents seem bigger than they are.
• Be preoccupied with fantasies about success, power, brilliance, beauty or the perfect mate.
• Believe they are superior to others and can only spend time with or be understood by equally special people.
• Be critical of and look down on people they feel are not important.
• Expect special favors and expect other people to do what they want without questioning them.
• Take advantage of others to get what they want.
• Have an inability or unwillingness to recognize the needs and feelings of others.
• Be envious of others and believe others envy them.
• Behave in an arrogant way, brag a lot and come across as conceited.
• Insist on having the best of everything — for instance, the best car or office.

At the same time, people with narcissistic personality disorder have trouble handling anything they view as criticism. They can:

• Become impatient or angry when they don't receive special recognition or treatment.
• Have major problems interacting with others and easily feel slighted.
• React with rage or contempt and try to belittle other people to make themselves appear superior.
• Have difficulty managing their emotions and behavior.
• Experience major problems dealing with stress and adapting to change.
• Withdraw from or avoid situations in which they might fail.
• Feel depressed and moody because they fall short of perfection.
• Have secret feelings of insecurity, shame, humiliation and fear of being exposed as a failure.

When to see a doctor

People with narcissistic personality disorder may not want to think that anything could be wrong, so they usually don't seek treatment. If they do seek treatment, it's more likely to be for symptoms of depression, drug or alcohol misuse, or another mental health problem. What they view as insults to self-esteem may make it difficult to accept and follow through with treatment.

If you recognize aspects of your personality that are common to narcissistic personality disorder or you're feeling overwhelmed by sadness, consider reaching out to a trusted health care provider or mental health provider. Getting the right treatment can help make your life more rewarding and enjoyable.

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It's not known what causes narcissistic personality disorder. The cause is likely complex. Narcissistic personality disorder may be linked to:

• Environment — parent-child relationships with either too much adoration or too much criticism that don't match the child's actual experiences and achievements.
• Genetics — inherited characteristics, such as certain personality traits.
• Neurobiology — the connection between the brain and behavior and thinking.

Risk factors

Although the cause of narcissistic personality disorder isn't known, some researchers think that overprotective or neglectful parenting may have an impact on children who are born with a tendency to develop the disorder. Genetics and other factors also may play a role in the development of narcissistic personality disorder.

Complications

Complications of narcissistic personality disorder, and other conditions that can occur along with it include:

• Relationship difficulties
• Problems at work or school
• Depression and anxiety
• Other personality disorders
• An eating disorder called anorexia
• Physical health problems
• Drug or alcohol misuse
• Suicidal thoughts or behavior

Because the cause of narcissistic personality disorder is unknown, there's no known way to prevent the condition. But it may help to:

• Get treatment as soon as possible for childhood mental health problems.
• Participate in family therapy to learn healthy ways to communicate or to cope with conflicts or emotional distress.
• Attend parenting classes and seek guidance from a therapist or social worker if needed.
• Narcissistic personality disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. 5th ed. American Psychiatric Association; 2022. https://dsm.psychiatryonline.org. Accessed Sept. 9, 2022.
• Narcissistic personality disorder (NPD). Merck Manual Professional Version. https://www.merckmanuals.com/professional/psychiatric-disorders/personality-disorders/narcissistic-personality-disorder-npd. Accessed Sept. 8, 2022.
• Overview of personality disorders. Merck Manual Professional Version. https://www.merckmanuals.com/professional/psychiatric-disorders/personality-disorders/overview-of-personality-disorders#v25246292. Accessed Sept. 9, 2022.
• What are personality disorders. American Psychiatric Association. https://psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders. Accessed Sept. 8, 2022.
• Lee RJ, et al. Narcissistic and borderline personality disorders: Relationship with oxidative stress. Journal of Personality Disorders. 2020; doi:10.1521/pedi.2020.34.supp.6.
• Fjermestad-Noll J, et al. Perfectionism, shame, and aggression in depressive patients with narcissistic personality disorder. Journal of Personality Disorder. 2020; doi:10.1521/pedi.2020.34.supp.25.
• Maillard P, et al. Process of change in psychotherapy for narcissistic personality disorder. Journal of Personality Disorders. 2020; doi:10.1521/pedi.2020.34.supp.63.
• Scrandis DA. Narcissistic personality disorder: Challenges and therapeutic alliance in primary care. The Nurse Practitioner. 2020; doi:10.1097/01.NPR.0000653968.96547.e7.
• Caligor E, et al. Narcissistic personality disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. https://www.uptodate.com/contents/search. Accessed Sept. 9, 2022.
• Caligor E, et al. Treatment of narcissistic personality disorder. https://www.uptodate.com/contents/search. Accessed Sept. 9, 2022.
• Allen ND (expert opinion). Mayo Clinic. Sept. 27, 2022.

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CONCEPTUAL ANALYSIS article

Narcissistic personality disorder: are psychodynamic theories and the alternative dsm-5 model for personality disorders finally going to meet.

• 1 Department of Forensic Special Education, University of Amsterdam, Amsterdam, Netherlands
• 2 Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
• 3 KU Leuven, Leuven, Belgium
• 4 Arkin, Amsterdam, Netherlands
• 5 Department of Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands

Narcissistic Personality Disorder is the new borderline personality disorder of our current era. There have been recent developments on narcissism that are certainly worthwhile examining. Firstly, relational and intersubjective psychoanalysts have been rethinking the underlying concepts of narcissism, focusing on the development of self and relations to others. Secondly, in the DSM-5, the Alternative DSM-5 Model for Personality Disorders (AMPD) was presented for a dimensional evaluation of the severity of personality disorder pathology. The combined dimensional and trait conceptualization of NPD opened the door to new integrated diagnostic perspectives, including both internal and interpersonal functioning. Finally, Pincus and Lukowitsky encourage clinicians to use a hierarchical model of pathological narcissism, as it opens up opportunities for shared points of interest in empirical research from different scholarly perspectives. As for most non-psychodynamic clinicians and researchers the DSM-5 clearly bears dominant weight in their work, we will take the AMPD model for NPD as our point of reference. We will discuss the narcissist's unique pattern of self-impairments in identity and self-direction, and of interpersonal disfunctioning (evaluated by assessing empathy and intimacy). Subsequently, we will examine how contemporary psychodynamic theories and the hierarchical model of Pincus and Lukowitsky additionally inform or contradict the AMPD. For us, one of the big advantages of the AMPD is the use of structured clinical evaluations of disturbances of the self and interpersonal functioning and the dimensional evaluation of severity. As psychodynamically oriented therapists, we are enthusiastic about the opportunities for inclusion of psychodynamic concepts, but we also discuss a number of sticking points.

Introduction

Narcissistic Personality Disorder is the new borderline personality disorder of our current era ( Choi-Kain, 2020 ). After three decades of progress have been made on Borderline Personality Disorder (BPD), Narcissistic Personality Disorder (NPD) now “… carries the potential for a new wave of investigation and treatment development.” Originally, narcissism was a psychoanalytic concept developed by Freud (1914) . It became a dominant theme in the 1970s in the fierce debate between the psychoanalysts Kernberg (1975) and Kohut (1972) . In the years that followed, few psychodynamic theoretical advances were made and research was scarce (as can be seen in Glasmann, 1988 ; Heiserman and Cook, 1998 ). However, in 1980, “given the increasing psychoanalytic literature and the isolation of narcissism as a personality factor in a variety of psychological studies,” narcissism found its way into the third Diagnostic and Statistical Manual of Mental Disorders (DSM-III; Frances, 1980 , p. 1053). Narcissism had established a foothold in the diagnostic “bible.” In the decades since, a robust body of research has not developed to test or substantiate Frances' assumption that narcissism is a specific personality factor. In a recent online literature search on PubMed, Choi-Kain (2020) found 27 times more articles for BPD than for NPD. Even worse, research has found a significant overlap between the diagnostic criteria for all personality disorders in DSM-IV and extreme heterogeneity in patients with the same diagnosis ( American Psychiatric Association, 2011 ). This conclusion was particularly clear in the case of NPD ( Miller et al., 2010 ; Pincus, 2011 ). Not surprisingly, in the discussion preceding the publication of the DSM-5 ( American Psychiatric Association, 2013 ), there was heated debate about radical changes to the criteria for personality disorder ( Skodol et al., 2011 ; Oldham, 2015 ). Thirty years after the inclusion of NPD in the DSM-III, it was almost removed from the fifth edition.

However, in the past two decades, there have been developments relating to narcissism that certainly merit examination. Firstly, relational and intersubjective psychoanalysts have been rethinking the concepts underlying narcissism, focusing on the development of self and relations to others ( Drozek, 2019 ). Secondly, an Alternative DSM-5 Model for Personality Disorders (AMPD) was established in the DSM-5 for the dimensional diagnosis of personality disorders alongside the strict categorical classification of personality disorders that had been used until then ( Bender et al., 2011 ; American Psychiatric Association, 2013 ; Skodol et al., 2014a ). In particular, the combined dimensional and trait conceptualization of NPD opened the door to new integrated diagnostic perspectives, including both internal and interpersonal functioning ( Ronningstam, 2020a ). Finally, Pincus and Lukowitsky's (2010) proposal for a hierarchical model of pathological narcissism opens up the prospect of looking beyond the relatively minor differences between competing theories about narcissism in order to find common ground.

In this article, we will examine if and how these recent developments can be integrated. We begin by providing an overview of contemporary psychodynamic theories on narcissism, followed by a description of the hierarchical model of narcissism and the AMPD for NPD.

New Theoretical Developments

Contemporary psychodynamic theories on narcissism.

An important question, clinically and conceptually, is what motivates human beings and makes them human. The traditional drive model posits that we are motivated by derivatives of innate aggression and sexual desires that can destabilize the ego or self. In recent decades, contemporary psychodynamic thinking has enriched conceptual knowledge about the motivational etiology and expression of narcissism. Turning away from the drive model implies relinquishing the assumption of specific narcissistic needs or a specific narcissistic phase in child development ( Meissner, 2008 ). Instead, contemporary relational psychoanalysis focuses on attachment, mentalization, relational needs, and motivational affective systems ( Modell, 1993 ; Panksepp, 1998 ; Akhtar, 1999 ; Meissner, 2009 ; Lichtenberg et al., 2011 ). As humans, we strive for development and homeostasis in self-organization, with biological and emotional forces playing an important role.

What shape does this take in optimal developmental circumstances? Self-organization develops with the adequate fulfillment of the emotional needs of babies and toddlers for attachment and emotion regulation ( Schore, 2003 ). These needs are met in reciprocal interaction with significant others and represented in the brain as internal working models about the self, relations, and others ( Bebee and Lachmann, 2002 ). In this development, the theory of object relations theory is also important. However, in the newer theories, the “relations” are based on a two-person psychology. These implicit working models are the materials for the “self-as-agent,” for sensing that you can prevent or make things happen. It is the blueprint for developing capacities for emotion regulation, attachment, mentalizing, reflective functioning, empathizing, and epistemic trust ( Fonagy, 2003 ). As babies and toddlers have no capacity for speech and symbolic thinking, the self-as-agent remains implicit and can only be experienced by enacting it.

As the capacity for language and symbolizing increases, however, preschoolers arrive at the realization of the self as a subject that experiences emotion: the self-as-subject develops. The self-experience of a preschooler is relatively conscious as a person who gives meaning to his or her life and is separated from, while simultaneously attached to, significant others ( Gergely and Unoka, 2008 ). Especially after the age of seven, the capacity for reasoning grows spectacularly and the child develops the capacity to self-reflect with a bird's eye view. Consequently, the self-as-object becomes integrated in a firmer sense of identity and the child constantly self-evaluates as in an inner dialogue ( Meissner, 2008 ). The growing capacity for self-evaluation develops alongside the capacity to experience self-conscious emotions such as shame, pride, jealousy, and envy ( Wurmser and Jarass, 2008 ; Schalkwijk, 2015 , 2018 ).

We will now look at how this relational theory of self-organization can be applied to narcissism. The most important factor is the chronic frustration of the basic biological need for satisfying reciprocal interactions. A child's or toddler's frustration sets the scene for the development of dysfunctional capacities for emotion regulation, attachment, mentalizing capacities, reflective functioning, and empathizing. The self-as-agent feels more powerless than able to make things happen. Ronningstam (2020b) writes: “As a central aspect of narcissistic functioning, sense of agency influences both self-regulatory and interpersonal functioning, such as attention seeking, competitiveness, and achievements” ( Ronningstam, 2020b , p. 91). These hampered capacities are part of the implicit self and thus operate outside of conscious awareness in the adult; they are ego-syntonic. Meissner (2008) and Symington (1993) suggest that, although not enacted “consciously” in the adult sense, the child has turned away from reciprocal interaction with others to protect his or her growing implicit self from chronic disappointment, from experiencing powerlessness instead of agency. Turning away from potentially frustrating interaction with significant others and opting for self-absorption is the core feature of pathological narcissism ( Auerbach, 1993 ; Lachmann, 2007 ). This can already be observed in preschoolers. Brummelman et al. (2016) showed that preschoolers with a high score for either self-esteem or narcissism are differentiated by the latter verbalizing that they are great, others are stupid, interaction with others is frustrating, and one is better off on one's own. Those with high scores for self-esteem verbalized that they are great, others are great too, and working together will make the results better. This can also be seen in adult life. When one of our patients was persuaded by his children to play his computer games in the living room instead of sitting in the attic, he said: “I see no additional value in sitting downstairs. It is irritating as my daughters want me to get involved in what they are watching on TV.” Basically, the patient was unable to experience the pleasure of being with someone. Inevitably, by turning away from others, a frail self-as-subject results, as it is built on frustrating self and other representations that miss benevolent, soothing, and realistic qualities. As a result, self-regulation is further impaired as the development of the self-as-object is hampered as well. The capacity for self-knowledge through reflection on the subjective self is underdeveloped, protecting the subject from painful shame ( Meissner, 2008 ). Consequently, in an unfortunate cumulation of hampered development, all aspects of the self are frail and self-regulation is dysfunctional.

Another relatively new psychodynamic theory, intersubjective psychoanalysis, has more to say about the dynamics of narcissism ( Benjamin, 2018 ; Drozek, 2019 ). By contrast with the basic need for satisfying reciprocal interactions posited by relational psychoanalysis, intersubjective psychoanalysis stresses the intrapsychic motivation for the intention to relate. Imagine not only being motivated by biological needs but also being intrinsically motivated to relate (“just for the fun of it”). Imagine wishing to recreate being in a relationship with another and re-experiencing the fulfillment that gives. According to Benjamin (2018) , this makes human beings fundamentally subjects who unconditionally value themselves and the other as individually dignified. Another fundamental characteristic of narcissism, in addition to incoherent self-organization, is a severe impairment of the intrinsic motivation to seek nearness and recognize the other as a subject.

In the next section, we will explore the trauma of narcissism and the associated suffering. Drozek (2019) states that patients with severe pathological narcissism (or borderline problems) find it impossible to value themselves unconditionally or ascribe unconditional value to others. They are therefore unable to be motivationally receptive to the subjectivity of others. “Rather, these patients are often only valuing aspects of the other (e.g., attentiveness, admiration, dependency) and valuing themselves only conditionally (e.g., contingent on their ability to appease the other)” ( Drozek, 2019 , p. 93). In this paper, we will not enter into the therapeutic implications of an intersubjective stance of this kind. We will go no further than pointing out that the therapist should actively assume responsibility for repairing ruptures in the relationship between the patient and the therapist ( Benjamin, 2018 ). Recognition from the therapist is insufficient for change; patients should also be actively engaged in recognizing themselves and the therapist/others. Recognition implies owning one's vulnerability and harmful aspects instead of projecting them onto the other.

The lack of intrinsic motivation for relating is associated not only with psychological distancing from and only conditionally valuing others, but also with another recent theoretical focus, namely, attachment theory. Diagnostically, one would expect insecure attachment styles. The lack of intrinsic motivation for relating would then emerge in a dismissive-avoidant attachment style, whereas the extrinsic motivation for relating, as seen in excessive reference to others for self-enhancement, would be seen in a preoccupied attachment style. Research into the relationship between pathological narcissism and attachment styles is scarce but it is growing. Banai et al. (2005) suggest that the painful longing for others to fulfill one's own needs may be a motivational component of attachment avoidance: “I don't need you!” Exploring early life experiences in a non-clinical sample, Cater et al. (2011) showed that narcissistic dynamics like entitlement, grandiosity, and vulnerability were associated with different parenting styles. Summarizing the research findings to date, Diamond et al. (2013) conclude: “Narcissistic disorders have been associated with dismissing-avoidant attachment status (…) but patients may also be characterized by preoccupied attachment status, in which the individual remains angrily or passively enmeshed with attachment figures” ( Diamond et al., 2013 , p. 533; see also: Ronningstam, 2020b ).

In the clinical and research literature, we see specific countertransference feelings in narcissistic patients as valuable contributions to the diagnostic process. In a clinical sample, independent of the therapist's theoretical orientation, age, or gender, NPD was positively associated with criticized/mistreated and disengaged countertransference, and negatively associated with a positive therapist response ( Tanzilli et al., 2015 , 2017 ). Further research in a sample of adolescents showed that grandiose narcissistic traits were associated with angry/criticizing and disengaged/hopeless therapist responses, whereas warm/attuned therapist responses fell short ( Tanzilli and Gualco, 2020 ). In addition, the quality of the therapeutic alliance was lower. Adolescents with hypervigilant traits received overinvolved/worried therapist responses and few angry/criticized responses 1 .

These countertransference reactions may indicate a dismissive attachment style in the patient. The negative association with positive therapist response confirms our clinical experience. As a patient said: “When you are so kind to me, I want to hit you!” The therapist's kindness or benevolence evokes shame: the patient, who is in a help-seeking, dependent position, finds the therapist's kindness humiliating. Envy can be used as a defense against shame: the patient envies the therapist's superiority and wants to take it away from him or her ( Morrison and Lansky, 2008 ). The dynamics between shame and envy express themselves in a self-focused competitive view of others that is considered to be a characteristic of narcissism. All relations here are thought to be about winning or losing, and mutual advantage is an unthinkable reality, as seen in the aforementioned research with preschoolers by Brummelman et al. (2016) .

In this paper, we depart from this contemporary relational and intersubjective line of psychodynamic theorizing, with characteristics such as the loss of reciprocal interaction, the loss of intrinsic motivation for seeking nearness, ascribing only conditional value to oneself and others, frail self-regulation, and the absence of the self-as-object. More traditional psychodynamic theories will not be replaced or dismissed and will continue to be referred to when applicable. Throughout this paper we will also refer to the Psychodynamic Diagnostic Manual, Second Edition (PDM-2, Lingiardi and McWilliams, 2017 ). The PDM-2 focuses on personality styles and not on personality disorders. Personality styles are “a relatively stable confluence of temperament, attachment style, developmental concerns, defenses, affect patterns, motivational tendencies, cultural influences, gender and sexual expressions and other factors–irrespective of whether that personality style can be reasonably conceptualized as ‘disordered”' ( McWilliams et al., 2018 , p. 299). The term personality disorder is used for personality styles “denoting a degree of extremity or rigidity that causes significant disfunction, suffering, or impairment” ( Lingiardi and McWilliams, 2017 , p. 17). The PDM-2 is based on the integration of the vast body of clinical experience with the richness of empirical research, thus departing from the DSM-5's fundament of empirical research only. In contrast to the DSM-5's striving for simplicity by ascribing fixed patterns of symptoms, the fundamental psychoanalytic premise in the PDM-2 is that doing complexity justice by acknowledging that “opposite and conflicting tendencies can be found in everyone ( McWilliams et al., 2018 , p. 300).”

The Hierarchical Model of Narcissism

Synthesizing theories about narcissism with the results from research and leaving the “narcissism of minor differences” behind, Pincus and Lukowitsky (2010) proposed that pathological narcissism is best conceptualized by a hierarchical model (see Figure 1 ). In their view, pathological narcissism is basically characterized by a combination of three psychodynamic phenomena: dysfunctional self-regulation, emotion regulation, and interpersonal relations.

Figure 1 . Pincus and Lukowitsky's model of narcissism.

They consider these three dysfunctional phenomena to represent the most basic building blocks of pathological narcissism. From this perspective, in contrast to the DSM-5 NPD classification, the Pincus and Lukowitsky model allows pathological narcissism to be situated on a continuum between two prototypes, which are covered by different terms in the clinical and research literature. At one end of the spectrum we find the prototype of grandiose, thick-skinned, arrogant/entitled, shameless, oblivious narcissism ( PDM Task Force, 2006 ; Gabbard, 2015 ). At the other end, we see the prototype of vulnerable, thin-skinned, hypervigilant, shame-prone, depressed/depleted narcissism: “This narcissistic vulnerability is reflected in experiences of anger, envy, aggression, helplessness, emptiness, low self-esteem, shame, social avoidance, and even suicidality” ( Pincus, 2013 , p. 95; italics Pincus). Although empirical evidence is still lacking, Pincus and Lukowitsky assume that grandiose and vulnerable narcissism can express themselves both overtly and covertly. “Thus, we might diagnose a patient with grandiose narcissism, with some elements being expressed overtly (behaviors, expressed attitudes and emotions) and some remaining covert (cognitions, private fantasies, feelings, motives, needs)” ( Pincus, 2013 , p. 96).

An interesting line of research was adopted by Russ et al. (2008) with the Shedler-Westen Assessment Procedure. They used atheoretical Q-sort methodology to identify, in addition to those described by Pincus and Lukowitsky, two subtypes of narcissistic personality disorder, as well as a high-functioning/exhibitionistic subtype. Patients with this third subtype, who are well represented in the clinical literature, “have an exaggerated sense of self-importance, but are also articulate, energetic, and outgoing. They tend to show good adaptive functioning and use their narcissism as a motivation to succeed” ( Russ et al., 2008 , p. 1479). This third subtype could be the prototype of the positive side of narcissism, a line which has not received much attention.

In their model, therefore, pathological narcissism is basically characterized by a dysfunctional regulation of self, emotions, and relations, which is remarkably consistent with contemporary relational psychodynamic theorizing. Pathological narcissism can therefore be situated between the poles of grandiose and vulnerable narcissism, which is consistent with traditional psychoanalytic theorizing but not with the original NPD concept in DSM-III and later editions. The idea that narcissism can express itself overtly and covertly is consistent with traditional psychoanalytic theory.

The Alternative Model for Personality Disorders

As stated above, the American Psychiatric Association (APA) discussion about the classification of personality disorders led to two different classification approaches in DSM-5. The first classifies the patient as usual in one of the official ten personality disorder categories, as described in section II of DSM-5. Clinicians and researchers can also adopt the new AMPD approach described in section III to assess patients' level of personality functioning and their unique trait profile. The assessment then consists of a mixture of clinical evaluation and the use of standardized instruments ( Skodol et al., 2014b ; Berghuis et al., 2017 ). In the AMPD, each personality disorder is characterized by a specific pattern of personality disfunctions and traits. In the case of narcissistic personality disorder, there is a unique pattern of self-impairment in identity and self-direction, and of impaired interpersonal functioning in empathy and intimacy. An NPD diagnosis is justified when at least two of these four elements are moderately or severely impaired. The specific traits to be assessed are grandiosity and attention seeking. It is interesting to note that, in PDM-2, the level of severity is established along the lines of Kernberg's concept of neurotic, borderline, and psychotic personality organization ( Lingiardi and McWilliams, 2017 ).

In the next section, we will address the four AMPD elements of personality functioning and its specified traits on the basis of current psychodynamic concepts and the hierarchical model described above.

Reflection on Personality Impairments in Narcissism

In order to integrate the recent developments discussed here, we need a point of reference. As is the case for most non-psychodynamic clinicians and researchers, DSM-5 clearly plays a role in our work, and so we will adopt the AMPD model for NPD as our point of reference. Subsequently, we will examine how contemporary psychodynamic theories and the hierarchical model of Pincus and Lukowitsky additionally inform or contradict the AMPD.

Evaluating Impairment of Identity

The AMPD conceptualizes identity impairment as:

- excessive reference to others for self-definition and self-esteem regulation;

- exaggerated self-appraisal, inflated or deflated, or vacillating between extremes; and

- emotional regulation mirrors fluctuations in self-esteem ( American Psychiatric Association, 2013 , p. 776).

This conceptualization addresses the function of others for self-definition and self-esteem regulation. Reference to others for self-definition is adequately described in traditional psychodynamic theorizing. Kohut (1972) emphasizes how the patient uses others instrumentally as objects for enhancing the patient's self, calling them “self-objects.” As soon as others no longer fulfill that function, their instrumental value becomes zero, and they are devalued as losers and discarded. Although this could appear to be counterintuitive, we argue that this applies not only to grandiose, but also to vulnerable, narcissism. In the latter, the patient enhances self-esteem by placing others in the spotlight.

Another counterintuitive combination is the AMPD's stress on “excessive reference to others” and the psychodynamic view that narcissism implies a refusal of reciprocal interaction with others and a lack of intrinsic motivation for nearness. The key to bringing together these seemingly different foci lies in the answer to the question “excessive reference to which self and which others?” The implicit self is consciously verbalized as a subjective self on the lines of: “I do not want to think and talk about the distress of my partner; I cannot bear it. It is too threatening to myself.” The narcissistic patient refuses to recognize the unconditional value of the other and to live in a reciprocal world. Indeed, others do “excessively” matter but not as unconditionally valuable subjects: their relational value depends on the instrumental function they serve for the regulation of the patient's self-esteem. We agree with Meissner (2008) , who sees narcissism as a psychodynamic function motivated by the need for “self-definition, self-development, self-organization, self-preservation, self-cohesion, self-enhancement, self-evaluation, self-regard, and self-esteem” ( Meissner, 2008 , p. 768). We are in favor of interpreting the strong focus on self-definition in AMPD's NPD as a focus on striving for coherence of identity. As for the quality of the excessive reference to others, we should not forget that, even if this reference becomes explicit, it is still located in the internal framework of a dysfunctional implicit self. Fonagy et al. (2002) add that the dysfunctioning of the self is further caused by the underdevelopment or absence of the self-as-object. Self-reflection and introspection are therefore impaired, and so is self-knowledge.

Identity is further conceptualized in the AMPD as “Self-appraisal inflated or deflated, or vacillating between extremes” and “Un-nuanced: self-loathing, self-aggrandizing, or an illogical, unrealistic combination” ( American Psychiatric Association, 2013 , p. 777). Likewise, in the PDM-2, the narcissistic personality style's central tension or preoccupation is inflation vs. deflation of self-esteem, whereas defense organization is dominated by idealization and devaluation ( Lingiardi and McWilliams, 2017 ). Combining this definition with psychodynamic theorizing, we must differentiate between two diagnostic groups. In patients with narcissism, the subconscious dysfunctional regulation of the subjective self lies in its incoherence, in the vacillation between black-and-white opposites of idealization and devaluation. The patient is therefore engaged in a constant struggle with himself or herself; even narcissistic grandiosity co-occurs with insecure self-representations and sensitivity to rejection ( Kealy et al., 2015 ). Caligor (2013) maintains that “as identity pathology becomes more severe, overt pathology in the sense of self as in the sense of others emerges” ( Caligor, 2013 , p. 71). In the other group who could fit this description, however, patients consciously suffer from low self-esteem. Their self is consciously experienced as consistently defective in only one direction: failing and coming up short.

Finally, the third element of identity impairment is “emotional regulation mirrors fluctuating self-esteem” ( American Psychiatric Association, 2013 , p. 777). In narcissism, emotions follow momentary self-esteem states whereas, in BPD, for example, self-esteem would appear to follow emotions more. One of our patients reported that her weekend had been depressing. She had frequently tried to help friends but, in the end, none of them had needed her. Where did that leave her? She felt useless and therefore depressed. The link between self-esteem and dysfunctional emotion regulation is characteristically expressed in the concept of narcissistic rage: the patient is extremely vulnerable to humiliation (perceived or otherwise) and strikes out when others are disappointing ( Kohut, 1972 ). The PDM-2 focuses on shame, humiliation, contempt, and envy as central affects ( Lingiardi and McWilliams, 2017 ). In a study of grandiose narcissism, shame was found to act as a mediating factor, reducing levels of aggression in patients with perfectionistic traits ( Fjermestad-Noll et al., 2020 ). Clinically, this vulnerability is strengthened by the experience of shame when identity is negatively evaluated. Much more than guilt, shame is associated with falling short of one's expectations of an ideal, grandiose self. Shame is differentially associated with the aspect of grandiosity vs. vulnerability. Generally, shame is absent or warded off in grandiose narcissism, whereas grandiose fantasies can alternate with intense shame about needs and ambitions in vulnerable narcissism ( Gramzow and Tangney, 1992 ; Dickinson and Pincus, 2003 ; Ronningstam, 2005 ). A more recent explanation for this fluctuation is that some patients with NPD tend toward mental concreteness, a refusal of symbolization or not symbolizing ( Ronningstam, 2020b ). This certainly has severe implications for the therapeutic alliance, the limitation of latitude for interpretation, and countertransference in the therapist.

Evaluating Impairment of Self-Direction

The AMPD conceptualizes the impairment of self-direction as: “Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement while frequently unaware of one's own motivations” ( American Psychiatric Association, 2013 , p. 767). The PDM-2 also describes as characteristic the pathogenic belief about self that “I need to be perfect to feel OK,” whereas the pathogenic belief about others is: “Others enjoy riches, beauty, power, and fame; the more of those I have, the better I will feel” ( Lingiardi and McWilliams, 2017 ).

With respect to the element of “goal setting based on gaining approval from others,” our clinical experience is that the patient can experience approval with no connection to reality. Consequently, others do not have to express their gratitude or approval in order to fulfill their instrumental function. In the splendid isolation of covert narcissism, admiring others can very well be imaginary: “Once I have published my solution for the global warming problem, everybody will admire me.” The internal (and possibly hidden) goal setting, which can take place in fantasy or daydreaming and with no footing in reality, is a particular inaptness in goal setting in covert narcissism that can be easily overlooked by clinicians.

The general inaptness of personal standards that is mentioned in the AMPD is clinically highly recognizable and consistent with psychodynamic theorizing. The suggested associations between “high standards and being exceptional” vs. “low standards and being entitled,” however, do not do justice to the converse clinical reality that high goal setting may also be based on the belief of being entitled and low goal setting on the belief of being exceptional anyway. Psychodynamic authors have provided good descriptions of the psychodynamics of shifting defenses in narcissism, in other words the warding of one emotion with another. For example, a patient can feel exceptional by setting extremely low standards, as in the patient mentioned above: “Once I have published my solution for the global warming problem, everybody will admire me. It's all in my mind, I just have to write it up when I feel it's time to do so.” Until then, the patient will just go on as usual, keeping a low profile.

Finally, AMPD and psychodynamic theorizing match up straightforwardly in the idea of being “often unaware of one's own motivations”: self-knowledge has to be avoided at any cost and often the patient has no conscious knowledge of struggling with his or her self-esteem or identity. We have already described the phenomenon in which the less patients can reflect upon themselves—an indication of weak reflective functioning—the more pathological narcissism is likely. To the best of our knowledge, little research has been conducted until now that specifically addresses the ability of reflective functioning in narcissistic patients ( Diamond et al., 2013 , Ronningstam, 2020b ).

In our clinical experience, narcissistic patients live their lives and use treatment at their own pace: “Time is on my side.” This makes treatment targeting inner change extremely difficult and time-consuming. Making narcissistic dynamics egodystonic and sensitizing the patient to hidden motives is one thing but handling the high levels of shame and anxiety that accompany the uncovering of the implicit self, which the patient feels compelled to ward off, is another ( Steiner, 2011 ).

Evaluating Interpersonal Impairment in Empathy

With the discussion of empathy, we enter the world of interpersonal difficulties encountered by narcissistic patients. The AMPD conceptualizes empathy as the: “Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- and underestimate of own effects on others” ( American Psychiatric Association, 2013 , p. 767).

The aspect of “impaired ability to recognize or identify with the feelings and needs of others” fits in well with Pincus and Lukowitsky's hierarchical model of pathological narcissism. In that model, impairment in interpersonal functioning is one of the three basic features of narcissism. Narcissism is accompanied by an impaired ability to identify the feelings and needs of others, the failure to recognize the other as a subject in her or his own right, and blocking reciprocity and mutual affect regulation ( Ritter et al., 2011 ). The patient does not expect to benefit from sharing emotions and is not intrinsically motivated to seek nearness. The impairment in empathy is not only found in impaired mentalizing: as patients are not willing to focus their attention on the other, they will also not want to respond emotionally to what can be experienced through empathy ( Allen et al., 2008 ). In clinical practice, the therapist's empathic interventions are often warded off by an empathic wall : “I don't want to be understood by you” ( Nathanson, 1986 ).

The qualification of the patient as being “excessively attuned to reactions of others, but only perceived as relevant to self” is very apt. In as much as others do not threaten to destabilize the patient's self-esteem, they are not in the patient's mind. If empathy does come into play, the quality of empathy is most likely to be extremely poor as others are perceived on the basis of the patient's subconscious blueprint of the implicit self. In research literature on empathy, there is a distinction between affective and cognitive empathy, which are represented in two different neural circuits ( Fonagy et al., 2002 ; Cuff et al., 2016 ). Clinically, if the patient has some empathic awareness of the other, we would expect cognitive empathy to be more associated with grandiose narcissism, and affective empathy to be more associated with vulnerable narcissism. Research, however, does not support our clinical experience: NPD patients have significant impairments in affective empathy, whereas cognitive empathy seems largely unaffected. Despite our clinical experience, Ronningstam (2020b , p. 84–85) concludes: “Further studies have provided evidence for compromised empathic function in NPD, that is, intact cognitive but neural-deficient emotional empathy, and impact of emotion intolerance and processing on ability to empathize ( Ritter et al., 2011 ).”

Evaluating Interpersonal Impairment in Intimacy

The AMPD conceptualizes intimacy as follows: “Relationships are largely superficial and exist to serve self-esteem regulation; mutually constrained by little interest in other's experiences and predominance of a need for personal gain” ( American Psychiatric Association, 2013 , p. 767). Relationships of this kind are related to the etiology of pathological narcissism represented in the blueprint of the implicit self: the inner representations of others are not based on an integration of differentiated images of self and others, nor are others recognized as autonomous subjects. Indeed, patients only send; they do not receive and they refuse reciprocity in relations with others. They hardly engage at all in inner self-talk as someone with a well-developed self-as-object would do to acquire more self-knowledge. It should be remembered that others are not seen as persons in their own right but rather experienced and used as instruments. In our clinical experience, therapists (and others) are most valued if they maintain an emotional distance and refrain from empathic interventions. This was seen in the example quoted above of the patient who said: “When you are so kind to me, I want to hit you!”

The need for personal gain can easily be misunderstood: the benefit is found in the enhancement of the subjective self. The instrumentality of relationships is a defense against the unbearable feeling of being dependent on the relationship ( Kernberg, 1975 , 1984 ). The exploitative quality of relations looks superficially like a “gain” but as therapists we should not forget that this gain involves a price: the patient lacks the capacity for self-soothing and existential loneness results. Characteristically, others are usually idealized or devaluated excessively and inappropriately. The patient may hyper-idealize others in order to comfortably warm him- or herself in the heat of their radiance: “Look how great we are!” (“mirror transference,” Kohut, 1972 ). Hyper-idealizing someone also places the patient in the position of being the one who has the expertise to judge, which fuels feelings of superiority. Excessive devaluation comes to the fore if the existence of the other threatens the stability of the subjective self by association: “Who am I, if I am associated with that loser?” A patient said to one of us: “Are you divorced? Because if you are, how can you help me with my relational problems when you can't handle them yourself?” The often bitter and aggressive nature of devaluation serves to enhance the subjective self. Idealization and devaluation are associated with an insecure dismissing-avoidant attachment style ( Tolmacz and Mikulincer, 2011 ). Ambivalence is seldom cherished as a valuable state of mind; instead, relations are about winning or losing, and jealousy is omni-present.

Anything with relational implications will be dismissed if it might give pleasure and make one emotionally alive. The evaluation of anniversary gifts is exemplary: a patient with grandiose narcissism said: “Getting presents for my anniversary is only a means of bringing more worthless trash into my house.” His vulnerable counterpart always bought himself a present after his birthday, shielding himself from the disappointment that others may not give him the “right” presents. Describing the basic relational patterns of patients with NPD, Lachkar (2008) writes that their partners are quite often diagnosed with BPD. It is a tale of the deaf leading the blind and, usually, the relationship falters when the partner with BPD matures and becomes less dependent and anxious.

Sexuality in relationships is often complicated. The patient tries to avoid the humiliation of having to display needs and wishes, and of experiencing vulnerability: “Hell is other people,” said Sartre (1943) . Psychoanalyst Green adds to Sartre's dictum: “Hell is not other people, but rather the body. … The body is a limitation, a servitude. … The body is his absolute master–his shame” ( Green, 1997 , p. 127). Sexuality is often reduced to a mere physical pleasure, whether or not permeated with fantasies of being the greatest lover. Extreme self-centeredness or other-centeredness during lovemaking is characteristic, as reciprocity and empathic attunement are avoided. The partner is treated instrumentally: “What value does the other's sexual pleasure have for myself as a lover?” A male patient broke up his marriage after discovering he had been lied to for years: with great shame, his wife had told him she was unorgiastic and had faked orgasms. His self-worth as a great lover crumbled.

Sexuality can turn into perverse love: sexual excitement becomes the substitute for love and the longing of the other serves to strengthen the cohesion in the self. The own body, the other's body, or a fetish becomes a sexual object, an eroticized self which is constantly longing for stimulation ( Akhtar, 2009 ). It is not uncommon to find NPD patients who also suffer from hypochondria: the frail implicit self has developed alongside a frail bodily self.

Reflection on the Narcissistic Personality Traits of Grandiosity and Attention Seeking

It should be remembered that the AMPD characterizes each personality disorder on the basis of a specific pattern of personality dysfunctions and traits. In the section above, we described the patterns of this pattern in NPD by looking at a unique pattern of self-impairments, which are evaluated by focusing on identity and self-direction, and of interpersonal functioning, which is evaluated by focusing on empathy and intimacy. We now turn to the unique trait profile of NPD: grandiosity and attention seeking.

Evaluating Personality Traits: Grandiosity

The AMPD conceptualizes grandiosity as “Feelings of entitlement, either overt or covert; self-centeredness, firmly holding to the belief that one is better than others; condescension toward others” ( American Psychiatric Association, 2013 , p. 768).

The description of feelings of entitlement, either overt or covert, fits in well with Pincus and Lukowitsky's (2010) suggestion that grandiose and vulnerable narcissism can be expressed both overtly and covertly and, consequently, that feelings of entitlement should not only be associated with grandiose narcissism. This perspective confirms our clinical experience but it is, at the same time, subject to some theoretical discussion. The first edition of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006 ) differentiated between an arrogant/entitled and a depressed/depleted subtype of narcissism ( Blatt, 1974 ). The PDM characterized “depleted self-imagery, angry, shameful, and depressed affects, self-criticism and suicidality, and interpersonal hypersensitivity/social withdrawal” ( Morey and Stagner, 2012 , p. 910). In the PDM-2, which focuses on personality styles and not on personality disorders, entitlement is mentioned only as a pattern in adolescents with narcissism ( Lingiardi and McWilliams, 2017 ).

The same applies to clinging to the belief that one is better than others and condescension toward others. These characteristics can also be seen in both expressions of narcissism, and particularly in masochistic narcissism: the grandiosity of suffering is hidden by silently and secretly experiencing the grandiosity of being able to bear any adverse events ( Fairbairn, 1940 ; Kernberg, 2007 ).

Entitlement and condescension are two characteristics of narcissism that have given narcissism its negative connotation in everyday speech. In psychodynamic theory, there is a close association between the nature of entitlement and a defensive wilful resistance to dependency and reciprocity. Patients wilfully decline to relate with another in order to get what they want; instead, they expect it to be served or granted without having to ask explicitly. Asking is about losing, as asking would acknowledge neediness and dependency. Research has shown that excessive and restricted forms of relational entitlement are significantly associated with insecure attachment styles ( Tolmacz and Mikulincer, 2011 ). In the clinical situation, we encounter patients who literally refuse to give up their entitlement. Their narcissistic rage is fuelled to no purpose by a feeling of entitlement and by the demand to be compensated for the misdeeds or shortcomings of persons or circumstances in the past. In our consulting room, we meet patients who cannot cut their losses with respect to situations in the past and, in their hate, remain attached to a parent in an obsessive and spiteful way. Working through this persistence is often painstakingly difficult because the rage prevents patients from establishing the psychological distance through the self-as-object that is necessary to see the insanity of their expectations.

Evaluating Personality Traits: Attention Seeking

The AMPD conceptualizes attention seeking as: “Excessive attempts to attract and be the focus of the attention of others; admiration seeking” ( American Psychiatric Association, 2013 , p. 768).

Again, it is easy to associate these criteria with overt narcissism and therefore fail to notice covert attention-seeking involving putting others in the spotlight. The essence of this latter type of self-esteem regulation is that patients subconsciously see their self-effacing behavior in the service of the well-being of others as support for their self-esteem. However—and this is essential—the relationship with the other is instrumental and can therefore be perceived by the other as manipulative. In intersubjective terms: the other is treated as an object that possesses conditional value. Even when the other is placed explicitly in the spotlight and patients do not get any exposure for themselves, the self-esteem of vulnerable patients may be enhanced considerably as they attribute the other's greatness to their own contribution (Kohut's “narcissistic mirroring needs”). Vulnerable narcissism is often found in persons who claim to function best as “the second person.”

Attention seeking therefore involves not only seeking admiration for oneself directly; it also includes forms of behavior in which admiration is given to others. This is a classic pitfall in treatment when, in the transference-countertransference matrix, the patient and therapist build up a mutual admiring collusion as both being “the best ever, together.” This form of covert, “eager to please,” narcissism is well-documented in psychoanalytic literature but often underdiagnosed in clinical practice. “Eager to please” narcissism is often associated with parentification in childhood ( Miller, 1981 ).

Concluding Remarks

In this article we integrated Pincus and Lukowitsky's (2010) hierarchical model of pathological narcissism, contemporary psychodynamic concepts of narcissism, and the diagnostic concept of narcissism in the AMPD.

Pincus and Lukowitsky encourage clinicians to use this hierarchical model as it opens up opportunities for shared points of interest in empirical research from different scholarly perspectives. Capacities for self-regulation and emotion regulation can, for example, be operationalized from social-learning theory and from a psychodynamic perspective, with each adding valuable knowledge. Pincus and Lukowitsky's valuable review showed there has been hardly any research into NPD with a clinical patient sample. More research involving a clinical sample is therefore needed. In addition, researchers could adapt their methods in order to conduct research that is clinically relevant for mental health care by focusing on phenomena that can be addressed in psychotherapeutic treatment. Pincus and Lukowitsky's review also showed that narcissism research is skewed by the use of the Narcissistic Personality Inventory, which mostly assesses adaptive expressions of grandiose narcissism. In the hierarchical model, vulnerable narcissism emerges as a relatively new concept for non-psychodynamically informed researchers and therapists, and additional measures have to be developed to cover this concept.

For us, one of the major advantages of the AMPD is the use of structured clinical evaluations of disturbances of the self and interpersonal functioning. In the present paper, we have discussed at length the thematic content of the AMPD. As psychodynamically oriented therapists, we are enthusiastic about the opportunities to include psychodynamic and structural concepts (see also: Bornstein, 2015 ). In addition to the thematic content, we welcome the dimensional evaluation of the severity of personality disorder pathology, as operationalized in DSM AMPD Criterion A, which can be assessed by instruments like the Semi-structured Interview for Personality Functioning (STiP-5.1) and Level of Personality Functioning Scale Self-Report (LPFS-SR) ( Hutsebaut et al., 2017 ), or scorings based on the Object Relations Inventory (ORI) ( Borroni et al., 2020 ).

In addition to the thematic content, we welcome the dimensional evaluation of the severity of personality disorder pathology. Kernberg's structural model for personality organization could provide an insight into the severity of all these thematic elements, in other words whether relevant psychodynamic features are organized in a neurotic or high-level/low-level borderline way. This provides the practitioner with information about the prognosis and the indication for the treatment model ( Caligor and Stern, 2020 ).

We also acknowledge that there are a number of discussion points. Following the example of all psychodynamic theories, the AMPD assumes in the case of NPD that there is a disturbance that goes back to early child development. However, in all honesty, there is still no empirically derived theory for the etiology of grandiose and vulnerable narcissism, even though there is now more research with children from researchers like Brummelman et al. (2016) . Relational psychodynamic theory has undeniably been supplemented with clinical child research into attachment, mentalization, emotion regulation, and parenting styles. It is, however, unfortunate that research has also shown that the link between childhood experiences and later emotional disturbances is relatively weak. More empirical data about attachment styles and emotion regulation styles in patients with narcissistic pathology would be welcome as support for the unique pattern of narcissistic relational dynamics.

In the final evaluation of the four AMPD DSM-5 elements of personality functioning, all the elements seem to have equal importance but clinical experience and psychodynamic clinical theory clearly place most emphasis on the element of identity, with self-regulation and emotion regulation as the most important aspect of this element. This problem can be resolved by further research into the relative importance of the four elements of personality dysfunction. The need to evaluate the severity of impairment in personality functioning is a valuable element in the proposed diagnostic criteria for NPD that psychodynamically oriented therapists could use to their benefit. We believe that the criteria for the two personality traits, grandiosity and attention seeking, rely too heavily on the definition of NPD in the traditional DSM-5, with its focus on grandiose narcissism. However, further research could determine whether only these two traits pertain to NPD or if other traits might be relevant as well. Future research using the Level of Personality Functioning Scale, as proposed in the AMPD, will provide ample opportunities for introducing a more sophisticated psychodynamic perspective.

The AMPD comes close to how psychoanalytic therapists could conceptualize their daily practice (see also: Caligor and Stern, 2020 ). As mentioned here, a positive aspect of the AMPD is that the diagnostic evaluation of the level of personality functioning is based on a structured clinical evaluation of four clinically relevant elements. The model addresses all the theoretical and clinical elements of pathological narcissism mentioned, such as self-regulation, affect regulation, interpersonal difficulties, grandiose/vulnerable, and covert/overt. In contrast to DSM-5 personality disorders in Section II, the AMPD clearly offers a more integrative approach. However, understandably, the basic tenet in clinical theory that distancing from the significant other forms the basis for developing NPD is not operationalized in the AMPD. Ultimately, this distancing can only be clinically inferred by assessing its consequences, which are described in the AMPD.

Now, after all this theory, the proof of the pudding is once again in the eating. In our case, the proof is to be found in the therapies we provide. Many guidelines for treating pathological narcissism have been developed in the last 10 years. Choi-Kain (2020) advocates using General Psychiatric Management, while others propose modifications of existing evidence-based treatment models for BPD to treat pathological narcissism: Mentalization-Based Treatment ( Drozek and Unruh, 2020 ), Transference Focused Psychotherapy ( Diamond and Hersh, 2020 ), Dialectical Behavior Therapy ( Reed-Knight and Fischer, 2011 ), or Schema Focused Therapy ( Young et al., 2003 ). Nevertheless, others focus on specific themes when treating pathological narcissism, for example in psychodynamic therapy ( Crisp and Gabbard, 2020 ) or the client-centered Clarification-Oriented Psychotherapy ( Maillard et al., 2020 ). Traditional high-frequency psychoanalysis—three to five weekly sessions on the couch—seems to have missed the boat in terms of establishing a position in the discussion.

After we concluded the draft version of this publication, the paper The “Why” and “How” of narcissism. A process model ( Grapsas et al., 2020 ) came to our attention. It comes from the field of social learning and experimental psychology. Almost none of the references in that paper overlap with those in the present paper. Given the realization that there are so many overlaps, it is shocking that we seem to know so little about each other's work. For example, both fields look at internal processing in subjects with narcissism. Grapsas et al. (2020) propose a self-regulation model of grandiose narcissism that illustrates an interconnected set of processes through which narcissists pursue social status in their moment-by-moment transactions with their environments. In the same way, Ronningstam (2020b) draws attention to internal processing in patients and how it contributes to narcissistic personality functioning. “Studies provide evidence for a neuropsychological core deficit in individuals with pathological narcissism or NPD, which affects their ability to access, tolerate, identify, and verbalize emotions” ( Ronningstam, 2020b , p. 85). Narcissism seems to be associated with many bioneurological phenomena that are prototypical for narcissism. Experimental research has found increased sensitivity to subtle cues of non-acceptance in facial expressions, the “denial” of physical shame reactions after being devalued, the rise of cortisol levels in situations of social threat, or the activation of brain regions sensitive to pain in response to exclusion. Ronningstam argues that more attention should be paid to all kinds of internal processing from a neuropsychoanalytic point of view. As in the treatment of traumatized patients, this approach could inform the therapist in therapeutic stalemates.

Affective neuroscience can enlighten the neurological correlates of our subjective states. Solms (2017) argues that striving for homeostasis of the self pertains specifically to “basic (brainstem) consciousness, which consists in states rather than images ” ( Solms, 2017 , p. 6). This is the self-system Schore calls the implicit self, associated with the unrepressed unconscious. Central to Schore's thinking is the notion that the idea of a single unitary self is misleading: “What we call the self is in reality a system of self states, that develop in the early years, but grow to more complexity during the life span” ( Schore, 2017 , p. 74). In the first year of life, the structuralization of the right brain self develops in the course of the interdependent interaction between child and caretakers ( self-objects ), especially through processes of mismatch and repair in attachment, and with it (mal)adaptive implicit self-regulation processes develop. In early development, this implicit self, supposedly located in the lateralized right brain, is basically relational, as the self-states develop out of the interaction with the self-objects. Schore (2009 , 2017) locates the brain's major self-regulatory systems in the orbital prefrontal areas of the right hemisphere. Its functioning belongs to the unrepressed unconscious; its content can be felt but cannot be translated into words or symbols. Accordingly, in psychotherapy, it cannot be reached through interpretations making the unconscious conscious, but it becomes visible in enactments between psychoanalyst and patient. Somewhat later in early development, after the second year, the verbal, conscious left lateralized self-system (“left mind”) develops. Schore writes: “Despite the designation of the verbal left hemisphere as “dominant” due to its capacities for explicitly processing language functions, it is the right hemisphere and its implicit homeostatic survival and affect regulation functions that are truly dominant in human existence” ( Schore, 2017 , p. 74).

The central challenge in the decade to come would seem to be to differentiate between NPD from BPD and to establish specific recommendations for treatment. Indeed, we agree with the comment made by Choi-Kain (2020) that was quoted in the introduction of this paper, that we can now look ahead to a new wave of investigation and treatment development.

Author Contributions

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors want to thank Lois Choi-Kahn for her comments on an earlier draft of this paper and Laura Muzi and Andrea Scalabrini for their helpful comments during the review process.

1. ^ This research outcome has been reframed by us, as Tanzilli and Gualco use different subtypes of narcissism.

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Keywords: narcissistic personality disorder, alternative model for personality disorders, psychodynamic theory, hierarchical model for narcissism, intersubjective psychoanalysis

Citation: Schalkwijk F, Luyten P, Ingenhoven T and Dekker J (2021) Narcissistic Personality Disorder: Are Psychodynamic Theories and the Alternative DSM-5 Model for Personality Disorders Finally Going to Meet? Front. Psychol. 12:676733. doi: 10.3389/fpsyg.2021.676733

Received: 05 March 2021; Accepted: 25 May 2021; Published: 15 July 2021.

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*Correspondence: Frans Schalkwijk, f.schalkwijk@gmail.com

† These authors share senior authorship

‡ These authors have contributed equally to this work and share last authorship

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