narcissistic personality disorder research

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Narcissistic personality disorder.

Paroma Mitra ; Tyler J. Torrico ; Dimy Fluyau .

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Last Update: March 1, 2024 .

• Continuing Education Activity

Narcissistic personality disorder (NPD) is a complex psychological condition that presents with a pervasive pattern of grandiosity, need for admiration, and lack of empathy. NPD can cause significant social and occupational impairment and often has complications of comorbid psychiatric and substance use disorders. This course discussion explores the historical evolution of the concept of narcissism, as well as the etiology, assessment, and treatment of NPD.

Structured within the context of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and its cluster-based classification, this activity navigates through Cluster B personality disorders, emphasizing the distinct characteristics shared among disorders like NPD, antisocial personality disorder, borderline personality disorder, and histrionic personality disorder. The session also critically examines the limitations of the DSM's clustering framework in effectively capturing the multifaceted nature of personality disorders. The integration of an interprofessional team is underscored, emphasizing a comprehensive approach to evaluation and treatment, aiming to mitigate the significant social and occupational impairments linked with NPD. The scarcity of effective treatment options for NPD is addressed, emphasizing the importance of early recognition and collaborative interventions for improved patient outcomes in the face of this challenging condition.

• Implement the current Diagnostic and Statistical Manual of Mental Disorders  diagnostic criteria for narcissistic personality disorder (NPD).
• Assess temperament and its specific characteristics in NPD.
• Determine the common history and mental status examination findings for a patient with NPD.
• Collaborate with the interprofessional team to enhance clinical outcomes for patients with NPD.
• Introduction

Narcissistic personality disorder (NPD) is a pervasive pattern of grandiosity, a need for admiration, a lack of empathy, and a heightened sense of self-importance. Individuals with NPD may present to others as boastful, arrogant, or even unlikeable. [1]  NPD is a pattern of behavior persisting over a long period and through a variety of situations or social contexts and can result in significant impairment in social and occupational functioning. [2] Additionally, NPD is often comorbid with other psychiatric illnesses, which may further worsen independent functioning. Unfortunately, treatment modalities for NPD are limited in both availability and efficacy. [1]

The term narcissism was first described by the Roman poet Ovid in his work  Metamorphoses: Book III . This myth centers around Narcissus, a character cursed to fall in love with his reflection. However, it was not until the late 1800s that narcissism was used to define a psychological mind state.

The psychologist Havelock Ellis first used the term narcissism in 1898 to link the description of Narcissus to behaviors he observed in his patient. [3] Shortly after, Sigmund Freud labeled "narcissistic libido" in his book  Three Essays on the Theory of Sexuality . [4] Psychoanalyst Ernest Jones described narcissism as a character flaw. [5]  In 1925, Robert Waelder published the first case report of pathological narcissism and described it as "narcissistic personality." [6]  Despite these developments, NPD was not included in the first edition of the  Diagnostic and Statistical Manual of Mental Disorders (DSM-I). It was not until 1968, during the era of the second edition of the DSM (DSM-II), that Heinz Kohut termed narcissism. [7]

In the DSM, personality disorders have been categorized into clusters based on shared characteristics; this model persists into the current DSM (fifth edition, text review) (DSM-5-TR). This categorization includes cluster A, cluster B, and cluster C personality disorders.  

• Cluster A:  Personality disorders with odd or eccentric characteristics, including paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder 
• Cluster B:  Personality disorders with dramatic, emotional, or erratic features, including antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder 
• Cluster C:  Personality disorders with anxious and fearful characteristics, including avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder 

Despite the historical context of using the cluster system, there are limitations when approaching personality disorders in this manner, and it is not consistently validated in the literature. [8]

There are very limited investigations and understandings of the etiology of NPD. A few behavioral genetic studies have demonstrated that NPD (and other cluster B personality disorders) is highly heritable. [9] [10]  Medical conditions are often associated with personality disorders or personality changes, specifically including those with pathology that may damage neurons. This includes but is not limited to head trauma, cerebrovascular diseases, cerebral tumors, epilepsy, Huntington disease, multiple sclerosis, endocrine disorders, heavy metal poisoning, neurosyphilis, and AIDS. [11]

Psychoanalytic factors contribute to the development of personality traits and disorders; however, narcissistic qualities are not implicity pathological, as narcissistic traits are a normal part of human development. Narcissism manifests around age 8, increases in adolescence, and decreases in adulthood. [12]  Still, individuals with a high degree of narcissism early in life tend to maintain a high degree of narcissism in later years. [13]  

Psychoanalyst Wilhelm Reich described "character armor" as defense mechanisms that develop with personality types to relieve cognitive conflict from internal impulses and interpersonal anxiety (eg, those with narcissistic tendencies have fantasy, projection defense, and splitting mechanisms). [14]  Negative developmental experiences such as being rejected as a child and ego fragility during early childhood may contribute to the development of NPD in adulthood. [15]  In contrast, excessive praise in childhood, including the belief that a child may have extraordinary abilities, may also develop into a lifetime need for constant praise and admiration. [16]  

Personality is a complex summation of biological, psychological, social, and developmental factors; therefore, each personality is unique, even amongst those labeled with a personality disorder. Personality is a pattern of behaviors that an individual adapts uniquely to address constantly changing internal and external stimuli. This is more broadly described as temperament, which is a heritable and innate psychobiological characteristic. [17] [18] However, temperament is further shaped through epigenetic mechanisms, namely through life experiences such as trauma and socioeconomic conditions, referred to as adaptive etiological factors in personality development. [19] [20] Temperament traits include harm avoidance, novelty seeking, reward dependence, and persistence.

Harm Avoidance  

Harm avoidance involves a bias towards inhibiting behavior that would result in punishment or nonreward. [21]  Individuals with NPD have relatively low harm avoidance; instead, they may act in general disregard for the consequences of their actions or view the potential gain from risky behavior as far outweighing the gamble of any potential harm that may result. Further, individuals with NPD are generally outgoing and have few social inhibitions.

Novelty Seeking  

Novelty seeking   describes an inherent desire to initiate novel activities likely to produce a reward signal. [22] Individuals with NPD have moderate-to-high novelty-seeking behaviors. They tend to be hot-tempered and social; some are thrill-seeking.

Reward Dependence  

Reward dependence describes the amount of desire to cater to behaviors in response to social reward cues. [23] Individuals with NPD have high reward dependence, to the point of demanding praise when completing tasks or forming new relationships. Individuals with NPD try to be social but for the sake of receiving praise or being seen in association with others of high status, which provides them with internal reward and validation.

Persistence  

Persistence describes the ability to maintain behaviors despite frustration, fatigue, and limited reinforcement. Interestingly, individuals with NPD are quite persistent, with an extreme desire to seek out a reward. They will persist in certain behaviors; however, this is generally one of their most major maladaptive traits, particularly when combined with their tendency for low harm avoidance. These individuals strive for higher accomplishments and social status worthy of praise. [23]

• Epidemiology

There are significant challenges in diagnosing NPD, as these individuals may not often present for psychiatric evaluation. High-quality and multipopulation measures are lacking. Prevalence rates from United States community samples have been estimated from 0% to 6.2% of the population. [24] Interviews of 34,653 adults who participated in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions revealed a lifetime prevalence for NPD of 6.2% (7.7% for men, 4.8% for women). [2]  

• Pathophysiology

There are limited investigations for neuroimaging in persons diagnosed with NPD. A voxel-based morphometry (VBM) study conducted in Germany with a small sample size showed gray matter decreased volumes in the prefrontal and insular regions. [25]  Another voxel-based morphometry and diffuse tensor imaging study showed grey matter reduction in the right prefrontal and anterior cingulate cortices. [26] Notably, these brain regions are associated with empathy, compassion, cognition, and emotional regulation processing. 

There is also a limited understanding of the psychological pathology in NPD. There are 2 proposed subtypes of NP: grandiose NPD and vulnerable NPD. [27] The grandiose subtype includes overt grandiosity, aggression, a profound lack of empathy, exploitation, and boldness. The vulnerable subtype presents with hypersensitivity and defensiveness and may be overlooked; these individuals may be more susceptible to affective disorders due to a fragile ego. [28]

• History and Physical

The presentation of NPD is highly variable. Persons with NPD generally speak from a place of self-importance and may demand or expect special treatment. In the clinical setting, amongst physicians, managers, and other high-ranking professionals, a patient with NPD may present as friendly while simultaneously presenting as cruel and bitter towards other staff not viewed as high-ranking. They may try to brag about their credentials and friends they view as having high status (ie, name-dropping). They are generally unable to handle criticism from peers or staff and frequently become enraged. [29] [30]  

The clinical history is likely to reveal tumultuous relationships. Often, these individuals become increasingly isolated as they grow older due to others having difficulty maintaining their friendships with those who suffer from severe NPD. Additionally, legal charges are often present in the clinical history, as individuals with NPD have difficulty following rules (or believing rules apply to them). [30] Descriptions of empathy are limited when discussing failed relationships. Although many individuals with NPD deny feelings of depression or any signs of perceived weakness, they often suffer symptoms of depression due to an underlying fragile ego perpetuated by socio-occupational impairment from their maladaptive behaviors. [31]

The mental status examination is completed in psychiatric evaluations and varies amongst each case of NPD. Still, the following areas should be carefully considered in the psychiatric evaluation of NPD. [32]  

• Appearance: The clinician should note the patient's general grooming and fashion choices. Clothing, accessories, hairstyles, or tattoos that are provoking may suggest NPD, as there is a sense of grandiosity and attention-seeking behavior characteristic of the disorder. 
• Behavior: The clinician should monitor for disinhibited behaviors, grandiose postures, smirking, and scoffing. The context of the patient's cooperation should be paid particular attention to, as it may vary greatly depending on who the individual interacts with (depending on their perceived status). 
• Speech: NPD may present with an increased amount of speech due to feelings of needing to prove oneself or brag about achievements and friendships, but there are no expected concerns with speech initiation, volume, or vocabulary.
• Affect: Affect is highly variable but may fluctuate greatly depending on the conversation topic, particularly if the patient with NPD feels challenged or threatened by the interviewer. More lability is expected than usual, with more frequent irritability. 
• Thought content: It is essential to assess for delusions in patients with NPD. The level of grandiose thought may border between nondelusional grandiose thoughts and delusional (psychotic) grandiose thoughts. Although this distinction does not impact the treatment plan, it does help the clinician assess the severity of NPD.
• Thought process: The thought process in NPD is generally concrete, with grandiosity being unchallengeable. Still, individuals with NPD have the capability for linear and logical thought, often used to achieve their initial accomplishments (higher education, careers, relationships of status).  
• Cognition: General cognition and orientation are not expected to be impaired in NPD but should be evaluated to rule out other psychiatric conditions.
• Insight: NPD is an egosyntonic disorder; therefore, a patient's understanding of their NPD is generally poor. Accepting self-deficit is usually not congruent with NPD.
• Judgment: The severity of NPD will impact a patient's judgment. This can often be assessed by inquiring of the patient's legal and relationship histories.
• Impulse control: The underlying temperament of NPD is classic for high reward dependence and low harm avoidance behaviors, which generally results in poor impulse control. This can also be assessed by inquiring about past legal and relationship history. 

Diagnosis of a personality disorder benefits from longitudinal observation of a patient's behaviors over various circumstances to give a broader understanding of long-term functioning. Because many personality disorder features overlap with symptoms during another acute psychiatric condition, personality disorders should generally be diagnosed when no acute psychiatric process is concurrently occurring. [33] However, this is not always possible or required, as in the cases of an underlying personality disorder contributing significantly to hospitalizations or relapse of another psychiatric condition (ie, major depressive episode). [34]  Still, it may take several visits with a patient to finally establish a firm diagnosis of NPD. 

Patients with cluster B personality disorders often display transference, which is a projection of their prior conflicts onto the clinician. Clinicians often develop counter-transference, which is when the clinician projects unresolved conflicts onto the patient. This frequently occurs due to the nature of the patient encounters for individuals who have personality disorders, as they may be aggressive, unreasonable to logic, or rude. [35]

Clinicians must recognize signs of counter-transference when they occur to remove any treatment bias that may impact the clinical care of a patient with NPD. [36]  Sublimation is a psychological defense mechanism that helps individuals transform unwanted or unhelpful impulses into less harmful or helpful ones. When clinicians begin to feel frustrated with patients who may be suffering from a personality disorder, it is useful (when possible) to sublimate the negative feelings of counter-transference and use those feelings instead as an evaluation tool to guide the differential diagnosis towards a personality disorder, which may ultimately direct the treatment plan. [37]

Various structured interviews and inventories have been developed to assist in evaluating NPD. Otto Kernberg's structured clinical interview, created in 1981, has continued to undergo revisions and restructuring as a structured clinical interview for personality disorders. The current version is a semistructured diagnostic interview with questions about personality organization, defenses, object relations, and coping skills. This interview focuses on interpersonal relationships. The Personality Institute at the Weill Cornell Institute copyrights the current version. The interview is based on psychodynamic principles and is expected to be used by persons with previous training in psychoanalytical work. [38]  

Other instruments may measure the severity of NPD, such as the five-factor narcissism inventory that looks at the 5 aspects of general personality. There are about 148 questions on the measure. [39]  Another measure that may be useful is the Narcissistic Personality Inventory. [40]  For formal diagnosis, the conglomerate of information provided by personal history, collateral information, mental status examination, and psychometric tools, individuals must meet the DSM-5-TR diagnostic criteria for NPD.

NPD  DSM-5-TR Criteria 

In interpersonal settings, there is a pervasive pattern of grandiosity, need for admiration, and lack of empathy. This pattern of behaviors onsets in early adulthood and persists through various contexts. Clinical features include at least 5 of the following:

• Having a grandiose sense of self-importance, such as exaggerating achievements and talents, expecting to be recognized as superior even without commensurate achievements
• Preoccupation with fantasies of success, power, beauty, and idealization
• Belief in being "special" and that they can only be understood by or associated with other high-status people (or institutions)
• Demanding excessive admiration
• Sense of entitlement
• Exploitation behaviors
• Lack of empathy
• Envy towards others or belief that others are envious of them
• Arrogant, haughty behaviors and attitudes  [1]
• Treatment / Management

Individuals with NPD may not recognize their illness as it is generally egosyntonic. The presentation is commonly at the behest of a first-degree relative or friend. Typically, this occurs after maladaptive behaviors have created stress on another rather than internal distress from the individual with NPD. Therefore, assessing the treatment goals in each specific NPD case is essential. As NPD is unlikely to remit with or without treatment, the focus of therapy may be aimed at reducing interpersonal conflict and stabilizing psychosocial functioning. [41]  

There is minimal evidence that pharmacotherapy helps treat NPD unless there is a comorbid psychiatric illness. There are no FDA-approved medications for the treatment of NPD [42] . Psychotherapy is likely the most preferable treatment for NPD despite there also being limited evidence for its efficacy. Transfered-focused therapy may have more success than other types of therapies. [43] [44] Case management can help assist patients with NPD in maintaining income, shelter, and connection to medical and mental health services, as well as assistance with other basic needs.

• Differential Diagnosis

NPD should be considered when a long-term pattern of rigid behaviors is observed over various internal and external stimuli. Many behaviors observed in NPD may overlap with symptoms of other psychiatric illnesses, so it is crucial to assess if NPD occurs in isolation or conjunction with another psychiatric condition. Grandiosity, irritability, and increased goal-directed activities are common symptoms of a manic or hypomanic episode in bipolar spectrum illness. However, there is no decreased need for sleep in isolated NPD. Additionally, manic and hypomanic episodes are acute episodes that are relatively short-lived and respond to medication treatment. In contrast, NPD is chronic and rigid and does not respond well to medication treatments. [27]

Other differential diagnoses include the other cluster B personality disorders, antisocial personality disorder, histrionic personality disorder, and borderline personality disorder. It bears mention that persons with NPD do not show overt signs of impulsivity and self-destructiveness associated with borderline personality disorder. [45] Similarly, apparent emotional responses are associated with histrionic personality disorder. NPD is most similar to antisocial personality disorder, with a lack of empathy and superficial charm. However, people with an antisocial personality disorder would show a lack of morals compared with people with NPD and have a past diagnosis of conduct disorder from adolescence. [46]

• Pertinent Studies and Ongoing Trials

There is a generally limited understanding of NPD, with high-quality population studies lacking. Most of our current knowledge is based on small sample-size investigations, case reports, or case series. Additionally, there are significant limitations to the existing models for describing all personality disorders. The cluster system has been most commonly utilized due to its implementation in the DSM. Despite behavioral similarity patterns that have been best attempted to be classified into syndromes (personality disorders), the individual uniqueness of each personality remains a problem for the diagnosis and research into each specific personality disorder. [8]  

Experts in personality disorders have suggested switching to a dimensional model of personality rather than a cluster model. The proposed dimensional models describe temperament, utilization of defense mechanisms, and identification of pathological personality traits. [47] Although the DSM-5 did not incorporate these recommendations due to the sudden radical change it would imply for clinical use, the paradigm will likely shift in the coming decades as further research solidifies in congruence with evolving clinical guidelines. This evolution is particularly evident as the DSM-5-TR incorporated this research into publication under the "emerging measures and models" section. Notably, in this section of the DSM-5-TR, some of the cluster model personality disorders have been removed, but NPD remains a named personality disorder.

Limited studies report and predict the outcome of NPD, although there is a consensus that the disorder usually lasts for life. [27]  An investigation from DSM-III era criteria found that NPD was less likely to have long-term impairment of global functioning compared to schizoid, antisocial, borderline, histrionic, and avoidant personality disorders. [48]  Ultimately, NPD is unlikely to resolve on its own or with treatment. Still, interventions to optimize quality of life, including reducing psychiatric comorbidity and stabilizing social factors, are likely to improve the prognosis of NPD. [42]

• Complications

Substance use disorders are common among personality disorders but with limited implications into which specific personality disorders pose the most risk for a particular substance use disorder. [49]  Personality disorders have an increased likelihood of suicide and suicide attempts compared to those without personality disorders, and individuals with NPD should be screened for suicidal ideation regularly. [42] [50]

• Deterrence and Patient Education

The treatment of NPD is dependent on developing and maintaining therapeutic rapport, particularly as these individuals may be highly sensitive to any suggestions or advice. Patients are encouraged to vocalize symptoms they would like addressed or any psychosocial stressors a treatment team can alleviate, rather than clinicians focusing on reducing behaviors if the patient is not in clinical distress or if they do not have a socio-occupational impairment.

Further, patients are encouraged to utilize support networks through their remaining social relationships. Involving the patient's family is another way of monitoring for decompensation and providing education on how to deliver stable social factors for the patient. [42]  Utilizing standardized assessments for quality of life may reveal ways to optimize the ability to function in significant areas of life for an individual with NPD. [51]

• Enhancing Healthcare Team Outcomes

The diagnosis and treatment of NPD is a complicated topic and is ultimately an area of psychiatric research that requires more study. As diagnostic and treatment models are shifting away from a cluster system and towards a dimensional model of personality, the implications that this will have on clinical practice will need close observation. Still, when a treatment team suspects NPD, a comprehensive history in conjunction with collateral information is recommended before formally diagnosing NPD. Including the patient's perspective and determining the appropriate goals of care for an individual with NPD is essential to prevent overmedicalization or iatrogenic harm to a patient who may not be suffering from any treatable symptoms. Collaboration with social workers, case managers, therapists, and family to optimize the social factors in a patient's life can offer stability to individuals with NPD. 

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Disclosure: Paroma Mitra declares no relevant financial relationships with ineligible companies.

Disclosure: Tyler Torrico declares no relevant financial relationships with ineligible companies.

Disclosure: Dimy Fluyau declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Mitra P, Torrico TJ, Fluyau D. Narcissistic Personality Disorder. [Updated 2024 Mar 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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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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• Patient Care & Health Information
• Diseases & Conditions
• Narcissistic personality disorder

Some features of narcissistic personality disorder are like those of other personality disorders. Also, it's possible to be diagnosed with more than one personality disorder at the same time. This can make diagnosis more challenging.

Diagnosis of narcissistic personality disorder usually is based on:

• Your symptoms and how they impact your life.
• A physical exam to make sure you don't have a physical problem causing your symptoms.
• A thorough psychological evaluation that may include filling out questionnaires.
• Guidelines in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Treatment for narcissistic personality disorder is talk therapy, also called psychotherapy. Medicines may be included in your treatment if you have other mental health conditions, such as depression.

Psychotherapy

Narcissistic personality disorder treatment is centered around psychotherapy. Psychotherapy can help you:

• Learn to relate better with others so your relationships are closer, more enjoyable and more rewarding.
• Understand the causes of your emotions and what drives you to compete, to distrust others, and to dislike others and possibly yourself.

The focus is to help you accept responsibility and learn to

• Accept and maintain real personal relationships and work together with co-workers.
• Recognize and accept your actual abilities, skills and potential so you can tolerate criticism or failures.
• Increase your ability to understand and manage your feelings.
• Understand and learn how to handle issues related to your self-esteem.
• Learn to set and accept goals that you can reach instead of wanting goals that are not realistic.

Therapy can be short term to help you manage during times of stress or crisis. Therapy also can be provided on an ongoing basis to help you achieve and maintain your goals. Often, including family members or others in therapy can be helpful.

There are no medicines specifically used to treat narcissistic personality disorder. But if you have symptoms of depression, anxiety or other conditions, medicines such as antidepressants or anti-anxiety medicines may be helpful.

More Information

• Cognitive behavioral therapy

Lifestyle and home remedies

You may feel defensive about treatment or think it's unnecessary. The nature of narcissistic personality disorder also can leave you feeling that therapy is not worth your time and attention, and you may be tempted to quit. But it's important to:

• Keep an open mind. Focus on the rewards of treatment.
• Follow your treatment plan. Attend scheduled therapy sessions and take any medicines as directed. Remember, it can be hard work and you may have occasional setbacks.
• Get treatment for alcohol or drug misuse or other mental health problems. Addiction, depression, anxiety and stress can lead to a cycle of emotional pain and unhealthy behavior.
• Stay focused on your goals. Stay motivated by keeping your goals in mind and reminding yourself that you can work to repair damaged relationships and become more content with your life.

Preparing for your appointment

You may start by seeing your health care provider, or you may be referred you to a mental health provider, such as a psychiatrist or psychologist.

What you can do

Before your appointment, make a list of:

• Any symptoms you have and how long you've had them, to help determine what kinds of events are likely to make you feel angry or upset.
• Key personal information, including traumatic events in your past and any current major stressors.
• Your medical information, including other physical or mental health conditions you have.
• Any medicines, vitamins, herbs or other supplements you're taking, and the doses.
• Questions to ask your mental health provider so that you can make the most of your appointment.

Consider taking a trusted family member or friend along to help remember the details. In addition, someone who has known you for a long time may be able to ask helpful questions or share important information.

Some basic questions to ask your mental health provider include:

• What do you think may be causing my symptoms?
• What are the goals of treatment?
• What treatments are most likely to be effective for me?
• In what ways do you think my quality of life could improve with treatment?
• How often will I need therapy sessions, and for how long?
• Would family or group therapy be helpful in my case?
• Are there medicines that can help my symptoms?
• I have other health conditions. How can I best manage them together?
• Are there any brochures or other printed materials that I can have? What websites do you recommend?

Don't hesitate to ask any other questions during your appointment.

What to expect from your mental health provider

To better understand your symptoms and how they're affecting your life, your mental health provider may ask:

• What are your symptoms?
• How do your symptoms affect your life, including school, work and personal relationships?
• How do you feel — and act — when others seem to criticize or reject you?
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• Published: 28 May 2024

Linking grandiose and vulnerable narcissism to managerial work performance, through the lens of core personality traits and social desirability

• Anna M. Dåderman   ORCID: orcid.org/0000-0002-8562-5610 1 &
• Petri J. Kajonius   ORCID: orcid.org/0000-0003-0629-353X 1 , 2  

Scientific Reports volume  14 , Article number:  12213 ( 2024 ) Cite this article

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• Human behaviour
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While grandiose narcissism is well-studied, vulnerable narcissism remains largely unexplored in the workplace context. Our study aimed to compare grandiose and vulnerable narcissism among managers and people from the general population. Within the managerial sample, our objective was to examine how these traits diverge concerning core personality traits and socially desirable responses. Furthermore, we endeavored to explore their associations with individual managerial performance, encompassing task performance, contextual performance, and counterproductive work behavior (CWB). Involving a pool of managerial participants ( N  = 344), we found that compared to the general population, managers exhibited higher levels of grandiose narcissism and lower levels of vulnerable narcissism. While both narcissistic variants had a minimal correlation ( r  = .02) with each other, they differentially predicted work performance. Notably, grandiose narcissism did not significantly predict any work performance dimension, whereas vulnerable narcissism, along with neuroticism, predicted higher CWB and lower task performance. Conscientiousness emerged as the strongest predictor of task performance. This study suggests that organizations might not benefit from managers with vulnerable narcissism. Understanding these distinct narcissistic variants offers insights into their impacts on managerial performance in work settings.

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Introduction.

Our comprehension of the impact of vulnerable narcissism on leadership remains in its nascent stages, and this study aimed to establish a data-driven foundation for further understanding. This endeavor is crucial for empirically examining vulnerable narcissism within organizational contexts. Research on CEOs personality predominantly centers on grandiose narcissism 1 , 2 , 3 or core personality traits such as conscientiousness and neuroticism 4 , but not on vulnerable narcissism. Recent work by Miller et al. 5 underscores the current knowledge and gaps in our understanding of various narcissistic constructs, emphasizing the necessity for additional exploration of narcissistic vulnerability itself.

While extensive research exists on grandiose narcissism among managers, the focus on vulnerable narcissism in managerial roles remains scant. Our aim was to explore two variants of narcissism—grandiose and vulnerable—within managerial roles, comparing and contrasting these traits with those observed in the general population. Moreover, within the managerial sample, we aimed to investigate the divergent correlations between both forms of narcissism and core personality traits, alongside examining their correlations with socially desirable responding. Additionally, we aimed to explore the associations between both variants of narcissism and managerial performance, encompassing task performance, contextual performance, and counterproductive work behavior.

To our knowledge, comparative analyses between managers and the general population regarding the level of these two narcissistic variants are lacking. However, it is recognized that employees in senior leadership positions tend to exhibit elevated scores of narcissism, as evaluated both by self-ratings and ratings provided by their subordinates 6 . Are managers more prone to grandiose narcissism and less susceptible to vulnerability compared to the general population? Would we anticipate observing a comparable pattern of divergent correlations between these two narcissistic variants and core personality traits in a sample of managers as is typically observed in the general population?

The focal point of managerial research, applying intricate methodologies encompassing numerous scales, predominantly centers on task performance 7 , 8 . Conversely, less attention is allocated to exploring alternative facets of individual performance, such as contextual performance. Previous studies have primarily examined the grandiose variant of narcissism in relation to work performance, revealing that narcissistic managers often overestimate their performance 9 , which may be related to socially desirable responding. However, it remains unclear whether this overestimation extends to other form of performance, including contextual performance. It would be intriguing to explore whether vulnerable narcissism predicts counterproductive work behavior, potentially indicating a need to prioritize the recruitment of managers with lower levels of vulnerable narcissism.

Grandiose and vulnerable narcissism defined

Morf et al. 10 offered a comprehensive delineation of the background and historical context surrounding the construct of narcissism. They traced its origins back to early depictions by scholars such as Havelock Ellis and Freud, who characterized narcissistic individuals as those excessively preoccupied with self-investment and the preservation of their ego, often to the detriment of others. Morf et al. 10 described narcissism as “self-enhancer personality” (p. 399). According to Morf and Rhodewalt 11 persons with narcissism are full of paradoxes, characterized by self-aggrandizement and self-absorption, yet paradoxically susceptible to perceived threats and overly sensitive to feedback. They exhibit emotional volatility across a spectrum from euphoria to despair and rage, whether in the role of a friend, boss, or romantic partner. Despite their charm and social adeptness, they display a marked insensitivity towards the feelings, desires, and needs of others. Initial attraction to such personalities may be common, only to be overshadowed by exhaustion from their incessant cravings for admiration and attention.

Narcissism, when considered at more formal and heightened levels, is classified as a personality disorder according to the Diagnostic and Statistical Manual of Mental Disorders 12 (DSM-5; APA). However, it is crucial to note that this study focuses on narcissism as a personality trait rather than as a diagnosable disorder.

For the last few decades, the Dark Triad traits—narcissism, Machiavellianism, and psychopathy, representing three socially aversive personality traits as outlined by Paulhus and Williams 13 —have garnered considerable attention as a focal point in research. This study focuses on narcissism, often regarded as comparatively less socially aversive in the workplace compared to other traits within the Dark Triad. Narcissism is a personality trait characterized by an inflated sense of self-importance and a need for excessive admiration 11 . There are two, at least in nonclinical samples unrelated, main variants of narcissism: grandiose and vulnerable (see review by Jauk and Kanske 14 ). Grandiose narcissists exaggerate their abilities, are arrogant, and seek power, while vulnerable narcissists are insecure yet still feel important.

In addition to the entitled behavior often associated with the grandiose variant of narcissism, vulnerable narcissism manifests in hypersensitivity and anxiety 15 , 16 . It tends to correlate with deflated self-esteem, depression, anxiety, and a lack of concern for others’ needs. Unlike the grandiose variant, vulnerable narcissism is not linked theoretically or empirically to overt self-reporting, such as bragging about successful organizational behaviors in the past 17 , 18 . Displaying proactive behaviors at work stems from a drive for status and power within the organization, rather than the characteristics of vulnerable narcissism.

The dichotomy of narcissistic grandiosity in organizational environments

In organizational settings, grandiose narcissism exhibits a dual nature, correlating with outcomes that can be either advantageous or detrimental. Employees with grandiose narcissistic tendencies demonstrate elevated confidence levels, a strong inclination toward achievement, and a readiness to assume leadership roles. These traits, particularly confidence and assertiveness, often facilitate their selection for managerial positions 6 . Kaiser 19 outlined that an abundance of narcissistic traits is often perceived as highly detrimental within managerial positions. The literature highlights narcissistic leaders as penchant for exploiting others, making impulsive decisions, and engaging in unethical behavior adversely impacts relationships and team performance 20 , 21 . For instance, CEOs narcissism is positively related to the likelihood that an organization will be subjected to a lawsuit 22 , to the manipulation of the reported earnings 9 , to incurring significantly higher audit fees from external auditors 23 , and tending to be bold in their actions and often engage in substantial risk-taking so as to demonstrate their self-perceived superiority to others 24 , 25 . Moreover, research has identified a negative correlation between grandiose narcissism and crowdfunding success. Specifically, it suggests that the higher the level of narcissistic personality traits in an entrepreneur, the lower the likelihood of successfully funding their crowdfunding campaign 26 .

However, the literature also underscores that grandiose narcissism possesses a dual nature, with certain positive attributes. For instance, research indicates that narcissistic entrepreneurs tend to gravitate towards more innovative and risky venture opportunities 27 . Additionally, within entrepreneurial teams, higher levels of narcissism are linked to improved business planning performance 28 . Previous research indicates that narcissistic managers exhibit various favorable traits that yield tangible benefits for organizations. They often embody charismatic leadership qualities, effectively navigating organizations through crises 24 , 29 , 30 , strive for higher performance by stimulating innovation 31 , and fostering a heightened entrepreneurial spirit 32 . Recent studies, such as that by Böhm and Blickle 29 , suggest that narcissistic leaders, particularly those high in political skill, possess the self-discipline to regulate aggressive tendencies while skillfully presenting their desire for admiration, thereby garnering acceptance from subordinates.

Narcissistic CEOs often emerge as visionary leaders 30 , partly due to their consistently optimistic communication with stakeholders 33 . Their narcissism correlates positively with engagement in corporate social responsibility (CSR) initiatives 34 , 35 , likely driven by the desire to garner heightened admiration for both them and their organizations through increased CSR investment.

Individual work performance

Work performance involves behaviors relevant to organizational goals and differs from productivity, which focuses on tangible outcomes. An employee’s effectiveness doesn’t always translate into high productivity due to various contextual factors. Evaluating individual performance encompasses goal-centric attitudes and actions like goal setting, time management, skill acquisition, and professional development. This multidimensional concept prioritizes observable behaviors over outcomes and spans task performance, contextual behaviors, and counterproductive work behaviors 36 .

Task performance refers to meeting job expectations in quantity, quality, essential skills, and professional knowledge. It includes planning, problem-solving, accuracy, knowledge maintenance, goal setting, and timely goal achievement. Contextual performance, also known as organizational citizenship behavior, goes beyond duties, encompassing actions like taking on extra tasks, initiating projects, engaging in collaborations, offering advice, and showing enthusiasm. However, counterproductive work behaviors (CWB) harm an organization, including complaints, negativity, off-task behavior, presentism, intentional mistakes, misuse of privileges, and exaggerating challenges.

Limited research has explored how narcissism influences individual work performance dimensions 37 , 38 , 39 . In managerial positions, the examination of narcissism primarily has focused on its correlation with task performance 40 . This study also considered other trait-based resources like effective coping strategies. Vulnerable narcissists struggle with self-worth, leading to sensitivity to criticism, social withdrawal, and engaging in CWB. Grandiose narcissists exhibit inflated self-importance, seeking admiration, and might display arrogant or exploitative behaviors 41 . Surprisingly, despite their traits, grandiose narcissists are less inclined to engage in CWB. Theoretically, shaping a distinct dynamic in their work performance, neurotic, vulnerable narcissists could potentially engage in CWB; however, this relationship has yet to be explored.

Narcissists generally tend to exaggerate their knowledge and possess an inflated self-centered view 42 . This would facilitate correlating positively with self-reported performance ratings among managers. However, challenges persist in task performance studies, prompting further investigation into social desirability responding in self-reported work performance.

The role of core personality traits

One popular dimensional model of core personality traits is the Five Factor Model (FFM/Big Five) 43 , breaking down personality into five broad domains 44 : extraversion, neuroticism, agreeableness, conscientiousness, and openness. Another model is HEXACO model 45 , which in addition of the traits encompassing Big Five also reflects honesty-humility. The consideration of whether narcissism contributes to the prediction of individual work performance beyond the core personality traits holds significance for two main reasons. Firstly, the Big Five traits are widely acknowledged to cover a substantial portion of the personality domain, with several of these traits demonstrating predictive power for leadership 46 and work-related ratings 47 , 48 . The trait most strongly predictive of job performance and a significant predictor of leadership, conscientiousness, generally shows little association with narcissism 49 .

Secondly, narcissism itself shares variability with some of the core traits, raising concerns about conceptual overlap. Specifically, grandiose narcissism exhibits positive correlations with extraversion and negative correlations with agreeableness and neuroticism 50 . In contrast, vulnerable narcissism is positively associated with neuroticism 14 , 50 . Both variants share aspects of exploiting others, relating negatively to honesty-humility 51 . Consequently, while controlling for the core traits may not diminish the impact of narcissism notably, it remains essential to include these traits particularly in work-related analyses for understanding the power of personality 52 .

The current study

Our study’s first objective was to compare two variants of narcissism in managers and people from the general population. Theoretical underpinnings and empirical evidence, aligning the grandiose variant with extraversion and the vulnerable variant with neuroticism, were considered. Given the complexity of managerial roles, where grandiose traits tend toward dominance and vulnerability manifests as defensiveness and insecurity, the anticipation was that managers would exhibit higher levels of grandiose narcissism and lower levels of vulnerable narcissism compared to counterparts in the workplace and the general population 53 .

Our study’s second objective was, within the managerial sample, to investigate the divergent correlations between both forms of narcissism and core personality traits, alongside examining their correlations with socially desirable responding. Assuming universality of core personality traits in humans 54 , and considering personality theory and past research 15 , 38 , 39 , 50 , 55 , 56 , we expected grandiose narcissism to show a positive correlation with extraversion and a negative one with neuroticism and agreeableness, while vulnerable narcissism to be positively correlated with neuroticism and negatively with extraversion and agreeableness 57 . Previous studies 50 , 51 , 58 have shown no notable link between conscientiousness and either form of narcissism. Therefore, we do not anticipate a significant relationship between conscientiousness and narcissism in our study. Moreover, we expected both grandiose narcissism 29 , 37 , 55 , 59 and vulnerable narcissism 51 to have negative correlations with honesty-humility. Narcissistic grandiosity may correlate with diminished levels of honesty-humility due to a proclivity for exploiting others. Conversely, narcissistic vulnerability is associated with abusive (aggressive) supervision tendencies 60 . Leaders harboring a vulnerable self-concept might resort to aggression against their followers, driven by internal attributions of failure and feelings of shame.

Our study’s third objective was to explore the associations between both variants of narcissism and managerial performance, encompassing task performance, contextual performance, and counterproductive work behavior. Different relationships with core personality traits would have implications for managers’ self-reports of their individual work performance. Acknowledging the limitations of self-reported work performance, our study aimed to control for core personality traits and socially desirable responses in these reports, ensuring a more comprehensive investigation. For instance, Ramos-Villagrasa et al. 39 demonstrated that while grandiose narcissism moderately correlated with contextual performance, it showed no relation to task performance or CWB. Relationships between vulnerable narcissism and the three individual work performance dimensions among managers have not been previously explored.

We formulated the following hypotheses:

Hypothesis 1

Managers, due to their role in leading others, were expected to demonstrate elevated levels of grandiose narcissism and decreased levels of vulnerable narcissism compared to persons in non-managerial roles.

Hypothesis 2

Grandiose narcissism would correlate positively with extraversion and negatively with agreeableness and neuroticism. It was also expected to exhibit a negative correlation with honesty-humility.

Vulnerable narcissism would correlate positively with neuroticism and negatively with extraversion and agreeableness. Similar to grandiose narcissism, it was anticipated to exhibit a negative correlation with honesty-humility.

It was not anticipated that conscientiousness would exhibit a significant correlation with either variant of narcissism.

Hypothesis 3

Grandiose narcissism, linked positively with extraversion, was predicted to be associated with higher levels of contextual performance in managerial roles.

Vulnerable narcissism, positively correlated with neuroticism, was expected to predict lower task performance and higher CWB among managers.

Materials and methods

Participants and procedure.

The study involved 344 managers, 57.8% being women, employed in various sectors in Sweden. On average, they were 49 years old, with around five years of managerial experience in their current roles. The dataset comprised managers from nine distinct organizations, with 70% in human-oriented sectors and the remaining 30% in manufacturing industries with positions ranging from superior (19.4%), intermediate (68.6%), to lower levels like group leaders (12%). These managers worked across fields like industrial production, social services, nursing, care services, and education. They were employed by privately-owned companies (45%), or municipalities and state organizations (55%). Eight organizations were situated in western Sweden, with one privately-owned municipality situated in Stockholm.

The data for this study were gathered within a leadership-focused project led by the first author. They engaged Human Resources (HR) managers from both municipal and private sectors throughout western Sweden, extending invitations to managers within these organizations to partake in the study. The HR managers received comprehensive project information, including details about the questionnaires and their measurement criteria, alongside an ethics statement. Subsequently, they relayed this information to their organizations’ CEOs. Upon agreement to participate, the HR managers supplied mailing lists containing potential participants.

Managers were asked to complete a web-based questionnaire using Google Forms, a free Internet-based software. Given the anonymous nature of the survey, researchers were unaware of which managers had already responded. To ensure adequate participation, all managers on the mailing lists received three reminder emails. Data collection occurred over a five-week period.

The response rates from the participating organizations were satisfactory, averaging 73% with a range between 65 and 81%.

Instruments

Aware of managers’ time constraints for lengthy surveys on psychological measures 61 , we opted for abbreviated versions of self-report instruments. A high scale score indicates a high value of the measured variable. We kept all items within the utilized instruments, even though this action may have slightly reduced the reliability measured by the scales’ Cronbach's alpha. Our goal was to enable a direct comparison of mean scale scores with other sample data. Notably, two variables (grandiose narcissism and openness) contained a few items that impacted their reliability. However, upon re-running the regression analyses, the results remained largely unchanged, showing only minor discrepancies.

Hypersensitive Narcissism Scale (HSNS)

The HSNS 57 measures vulnerable narcissism using responses ranging 1–5, Very uncharacteristic or untrue, strongly disagree to Very characteristic or true, strongly agree. The index is derived from the sum of items, resulting in a possible range between 10 and 50. The Swedish version (translated by Björkman and Kajonius, revised by Hellström) was used (see Supplementary Information for HSNS in both English and Swedish).

Short dark triad (SD3)

The SD3 62 comprises three scales, but only items from the subclinical Narcissism (the grandiose variant) scale were sampled. The SD3 uses responses ranging 1–5, from Strongly disagree to Strongly agree . The Swedish version (translated and adapted by Lindén and Dåderman) is published 63 .

Individual Work Performance Questionnaire (IWPQ)

The IWPQ 64 comprises three scales: task performance, contextual performance, and counterproductive work behavior (CWB). IWPQ measures individual work performance using responses ranging 1–5, from Seldom to Always for task and contextual performance, and from Never to Often for CWB. All items have a recall period of 3 months. The Swedish version is published 7 .

Mini international personality item pool-6 inventory (Mini-IPIP6)

The Mini-IPIP6 65 measures core personality traits comprising six scales: neuroticism, extraversion, openness, agreeableness, conscientiousness, and honesty-humility. The Mini-IPIP6 uses responses ranging 1–7, from Strongly disagree to Strongly agree . The Swedish version (translated and adapted by Backström, Dåderman, Grankvist, Kajonius, and Lundin) is published 63 .

Balanced inventory of desirable responding (BIDR 6) 66 , 67

BIDR 6 comprises two measures for socially desirable responding using responses ranging 1–7, from Not true at all to Completely true . These can be separated into unconscious self-deceptive enhancement and conscious impression management 68 , 69 . Self-deceptive enhancement is a stable personality characteristic, while impression management depends on the characteristics of the situation a person is in 69 . The Swedish version (translated by Grankvist and Lundin) was used (see Supplementary Information for BIDR 6 in both English and Swedish).

Data management and statistical analyses

All statistical analyses were performed in SPSS 28. Single missing values (< 1%) were replaced by the mean for all cases. We computed means and standard deviations of the variables. Internal consistency of the scales was determined using Cronbach’s alpha 70 . Because we used short scales comprising a few items, we also calculated mean inter-item correlations.

To evaluate Hypothesis 1 , aimed at distinguishing between two distinct variants of narcissism among managers and the general population, we conducted one-sample t -tests across several samples. Data on narcissism were sourced from published studies or directly obtained from the authors of the Swedish versions of the SD3 and the HSNS. The weighted mean differences were calculated for the SD3 and HSNS narcissism average scores obtained by the authors of the citied studies (see Table 1 for details), and compared to our sample’s average score using one sample t -tests. In line with Erkoreka and Navarro 71 , it was imperative to recalculate the data collected from Hendin and Check’s 57 samples.

To evaluate Hypothesis 2 , how the variants of narcissism relate to core personality traits, we employed Pearson correlation coefficients (see Table 2 ).

To evaluate Hypothesis 3 , how these predict managerial work-related performance, we performed three hierarchical regression analyses. Both variants of narcissism were entered as predictors in the first step. Subsequently, all six core personality traits were included in the second step, followed by the two scales measuring socially desirable responding in the final step.

We adhered to effect size guidelines in individual differences research, such as considering r  = 0.20–0.30 as indicative of a medium effect 72 . Cohen’s d values are typically interpreted as follows: 0.20 represents a small effect (might not be discernible to the naked eye), 0.50 signifies a medium effect, and 0.80 indicates a large effect (are easily visible without aid) 73 .

Ethical statement

This study adhered to the Swedish Research Council’s guidelines. Data were collected in 2017 in accordance with Swedish law (2003:460, §2). Approval was secured from participating organization leaders, and the project’s data handling was officially sanctioned by Municipal Academy West (Diary no. 100127). All experimental protocols were approved by the Ethics Committee at Lund University. Prior to accessing the questionnaire, participants were informed about purpose of this study, and that their participation was voluntary and confidential, with guaranteed anonymity and the option to withdraw at any time. The questionnaire did not inquire about sensitive personal data. Written informed consent was obtained from all participants following the Declaration of Helsinki.

How does narcissism vary between managers and people from the general population?

Table 1 demonstrates a notable distinction between the present group of managers and samples from the general population. Particularly, these managers showcased significantly higher mean scores in measuring grandiose narcissism and notably lower scores in vulnerable narcissism. Therefore, Hypothesis 1 finds support. The observed variance ranged from small to considerable for grandiose narcissism and notably substantial for vulnerable narcissism.

Table 2 illustrates the correlations between core personality traits, socially desirable responding, and the two observed variants of narcissism within our manager sample. In line with Hypothesis 2a, grandiose narcissism showed a strong positive correlation with extraversion. However, contrary to Hypothesis 2a, grandiose narcissism did not display the expected negative correlations with neuroticism and agreeableness. Similarly, in line with Hypothesis 2b, vulnerable narcissism showed strong positive correlations with neuroticism and negative correlations with extraversion and agreeableness. Both narcissism variants demonstrated clear negative correlations with honesty-humility, aligning with Hypotheses 2a and 2b. Contrary to Hypothesis 2c, which posited that conscientiousness would not significantly correlate with either variant of narcissism, it is notable that grandiose narcissism unexpectedly displayed a negative significant correlation with conscientiousness. However, in line with Hypothesis 2c, vulnerable narcissism did not exhibit a significant correlation with conscientiousness. Consistent with Hypotheses 3a and 3b, the correlations between the two narcissism variants and the three dimensions of individual work performance revealed contrasting trends, prompting further investigation through regression analyses in subsequent steps.

We incorporated measures to account for socially desirable responses. Notably, impression management, reflecting conscious misrepresentation, strongly correlated negatively with vulnerable narcissism, CWB, and neuroticism, while positively correlating with honesty-humility. Meanwhile, self-deceptive enhancement, a subconscious positivity bias in responses, displayed a strong positive correlation solely with conscientiousness.

Predictions of managerial work performance

In order to test hypothesis 3, we performed regression analyses on work performance (IWPQ), using the dimensions of task performance, contextual performance, and CWB as dependent variables. To isolate the distinct impact of narcissism while accounting for core personality traits and socially desirable responding, we conducted three separate hierarchical linear regressions, one for each dependent variable. The detailed outcomes of these analyses can be found in Table 3 .

In summary, after controlling for the role of core personality traits and socially desirable responding, grandiose narcissism didn’t predict work performance variables, while vulnerable narcissism and neuroticism predicted higher CWB and lower task performance. Conscientiousness stood out as the most influential predictor of task performance, while extraversion as the most influential predictor of contextual performance. These findings were adjusted for self-deceptive enhancement, a variable found to have no significant influence on any dimension of individual work performance. Impression management, however, negatively influenced CWB.

This study aimed to bridge existing gaps in managerial literature by shedding light on the comparison of mean values of narcissistic variants among managers with people from the general population. It examined their divergent correlations with core personality traits, while also considering socially desirable responding. Furthermore, it explored their associations with various forms of managerial performance, encompassing task performance, contextual performance and counterproductive work behavior.

Only a few studies 37 , 38 , 39 have investigated narcissism’s relationships with the three dimensions of individual work performance 36 . However, these studies encompassed broader participant groups beyond managerial roles and didn’t specifically target vulnerable narcissism. Among these, Ramos-Villagrasa et al. 39 revealed a noteworthy correlation ( r  = 0.23) between task performance and grandiose narcissism. Interestingly, existing findings consistently showed a moderate correlation (approximately r  ~ 0.20) between grandiose narcissism and contextual performance, including our study. However, after controlling for core personality traits and social desirability responding, this significant association disappeared (Table 3 ), which other studies have not analyzed. Notably, our study unveiled consciousness as the most influential predictor of contextual performance, a novel but not surprising discovery. Aligning with prior research, our study corroborated the minimal impact of grandiose narcissism on CWB.

Our study expanded upon prior research, particularly Miller et al. 50 , by examining a sample comprised exclusively of managers, revealing an absence of significant correlation between grandiose leadership and vulnerable narcissism (Table 2 ). The table highlights a novel finding within the managerial sample: contrary to Hypothesis 2a, grandiose narcissism did not exhibit the anticipated negative correlations with neuroticism and agreeableness. Additionally, it is noteworthy that grandiose narcissism unexpectedly demonstrated a negative significant correlation with conscientiousness. These results diverge from those observed in the general population 50 , 56 . We will endeavor to elucidate these inconsistencies. These findings may be illuminated by the distinct differences in narcissistic tendencies observed between our manager-only sample and samples drawn from the general population. Specifically, managers exhibited higher levels of grandiose narcissism and lower levels of vulnerable narcissism (see Table 1 ). Another potential explanation for the lack of a negative correlation between grandiose narcissism in managers and agreeableness could be attributed to a prevalent cultural norm in Swedish workplaces known as “jäntelagen,” which emphasizes a tendency to agree and maintain politeness with coworkers. Agreeableness reflects a disposition towards trust, compassion, and kindness. Managers high in agreeableness tend to foster positive interpersonal connections, prioritize cooperation, and seek to prevent conflicts. The majority of the participants are women, and it is well-documented that women typically exhibit higher levels of agreeableness compared to men 44 . Likewise, the absence of a negative correlation between high grandiose narcissism and neuroticism may be attributed to a cultural norm prevalent in Swedish workplaces, characterized by strong employment regulations that ensure job security.

A final notable contribution of our study was the exploration of vulnerable narcissism’s impact on the three dimensions of individual work performance (see Table 3 ). Through regression analyses, while adjusting for core personality traits and socially desirable responding, our results indicated that only vulnerable narcissism and neuroticism emerged as significant predictors of CWB. Vulnerable narcissism also negatively predicted task performance, although the strength of this association was limited. Furthermore, our study unveiled that grandiose narcissism related positively to self-deceptive enhancement, while vulnerable narcissism related negatively with impression management—a novel finding likely unreported in prior literature.

Strengths and limitations

While the study’s cross-sectional design presents a limitation, it is noteworthy that the current research achieved a commendably high response rate (73%), which enhances the representativeness of the conclusions drawn for Swedish managers. A notable strength lies in the sample size, which encompasses leaders across diverse managerial roles and organizations. This diversity in the sample enhances validity by introducing greater variation, enabling robust analyses. Importantly, our findings suggest a potential universal efficacy of specific managerial qualities across varied organizational settings. This strength contrasts with past research, as noted by Cycyota and Harrison 74 , where obtaining high response rates and large sample sizes was challenging and often resulted in limited data availability.

Another notable aspect of this leadership project lies in the thoroughness of the managers’ participation, as evidenced by their completion of the comprehensive survey encompassing various psychological measures 40 . Bednar and Westpha 61 observed that managers, particularly those in senior positions, seldom recognize the value or find the time to undertake lengthy surveys pertaining to psychological measures. While these measures have been translated and justified for use 40 , 52 , 75 , understanding any nuances regarding how narcissism presents in Sweden compared to other contexts would be beneficial. Consistent and reliable results across Western countries have, however, not been found. Nevertheless, utilizing different instruments than those used in our study, there seems to be a discernible trend indicating that in more modern, progressive, and individualistic societies, there is a lower prevalence of narcissism 76 , 77 .

Moreover, the study’s strength also lies in its approach to evaluating work performance, encompassing not just task-oriented metrics but also various other performance indicators. This inclusive evaluation acknowledges the nuanced nature of managerial behavior, emphasizing the need for a balanced focus on both task-oriented (such as transactional behaviors, initiating structure, and boundary spanning) and person-oriented (such as transformational behaviors, consideration, empowerment, and motivational behaviors) leadership styles 78 .

Although gathering self-report data can pose challenges, it is crucial to acknowledge the potential biases inherent in such data, which could have impacted the precision of trait measurements. This concern is salient when evaluating traits such as grandiose narcissism, often viewed as advantageous in leaders. Despite attempts to alleviate social desirability bias, inherent limitations endured. Self-reported evaluations, susceptible to social desirability bias, are prone to distortion, especially among persons with narcissistic tendencies. This distortion often manifests as exaggerated or fluctuating self-appraisals. Narcissists are known for their adeptness at deceptive communication 79 with a strong inclination towards self-enhancement and perceived superiority 80 , 81 , particularly concerning positive traits and their perceived leadership competence. Table 3 indicates some of these tendencies. Notably, the positive association between impression management—conscious attempts to manipulate perceptions—and honesty-humility aligns with the societal preference for honest leaders. Conversely, impression management exhibited negative correlations with CWB and neuroticism, both widely recognized as undesirable traits in managerial roles. This suggests a deliberate and subconscious drive among managers to present themselves as task-oriented leaders, both for their self-image and others’ perceptions.

Conclusions and implications

This study serves as a foundational step towards empirical comprehension, seamlessly integrating with existing literature. One conclusion is that vulnerable narcissism (and neuroticism) exhibited a detrimental impact on task performance, while grandiose narcissism (and extroversion) had a positive relationship. Neither form of narcissism was significantly related to contextual performance, while counterproductive work behavior was clearly associated with vulnerable narcissism (and neuroticism). Our conclusions suggest that organizations emphasizing task performance in managers may not benefit from managers exhibiting vulnerable narcissism or high neuroticism. Instead, recruiting managers with high extroversion and conscientiousness could be more advantageous.

Data availability

The data underlying the results presented in the study are published 27 December 2023, and available on Mendeley Data ( https://doi.org/10.17632/94rsp7bw9x.1 ).

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• Personality

Hope for Narcissism and Other Personality Disorders

A compassionate approach to treating tough disorders..

Posted June 3, 2024 | Reviewed by Abigail Fagan

• What Is Personality?
• Find a therapist near me
• People with personality disorders struggle with relationships with self and others.
• Mentalization-based therapy utilizes technique to improve one's ability in these areas.
• Research evaluating the impact of MBT on personality disorders is promising.

I remember sitting in the basement of a large academic building in an undergraduate psychopathology class. The topic: personality disorders . The outlook: bleak. I found it tricky to separate the person from the disorder. After all, what is the difference between one's personality , and self?

Years later, after working in depth with several individuals given a diagnosis of a personality disorder, I personally believe that our core self cannot be disordered. What we call personality disorders represent significant disruptions in our relationships with self and others. Alterations to these relationships are not the same as changes with a person at their core. People diagnosed with personality disorders ranging from narcissistic personality to schizotypal personality are first and foremost people. Like others, those diagnosed have dreams , fears, pains, joys, and often a desire to recover.

I have come to view these more as adult presentations of attachment disorders than as character or identity problems.

Mentalization-Based Therapy

Mentalization-based therapy (MBT) is a psychotherapy option for individuals living with personality disorders (Bateman and Fonagy, 2016). Mentalization is the ability to keep our and others' mental states in awareness as we interact. We all struggle with this at times, but personality disorders create immense difficulties in these areas.

In personality disorders, an attachment style has formed wherein a person is relating in problematic ways. Such styles are often shaped through one's childhood . These patterns are typically outside a person's awareness. Through MBT, the clinician and client collaboratively explore these. The therapist often takes a 'not-knowing' stance, presenting themselves as a sort of fellow traveler rather than an expert who is quick to assign judgment. The hope is that such a stance will maintain effective mentalizing on behalf of the practitioner. When we are stressed , all of us, including therapists, tend to land in non-mentalizing modes.

In MBT, non-mentalizing modes are described as traps that prevent us from fully relating with ourselves and others. While everyone falls into these at times, when such patterns become pervasive, severe problems can occur in our relationships and sense of self. Non-mentalizing modes include psychic equivalence, pretend mode and teleological mode.

Psychic equivalence is an experience where one's perception is seen as the absolute truth. Although there might not be good evidence, when we are in a mind frame of psychic equivalence, whatever we see on the inside becomes so on the outside. One way this might manifest is during certain expressions of fear of abandonment in people with borderline personality disorder. For example, one person might have an almost unshakable sense of being unloveable and project that into believing a single person is planning to leave them.

Pretend mode is a space where someone may paint a picture of what they or others are experiencing without grounding. It often involves the creation of a narrative based on little evidence. In a sense, it is a sort of fantasy . One image that comes to mind would be an incarcerated person sharing a story that "everything is fine."

Lastly, the teleological mode requires something physical on the outside in place of internal states. A teleological overfocus on the tangible stops us from perceiving the more complex interaction between ourselves and others. One possible way these could show up would be someone making a special request for a sense of 'proof' that they are indeed exceptional. Such a need for concrete evidence is seen in a variety of settings, but a persistent desire for special status is a hallmark of a narcissistic personality.

Another way that teleological mode might show up would be dismissing something another person is experiencing as something physical. For example, if a person's partner expresses concern about the relationship think, "Well, she must just be overtired" rather than looking any deeper.

These non-mentalizing modes describe just a few of the relational processes considered in MBT.

Rather than focusing on behavior, MBT is more attachment-focused, seeking the objective of improving relationships with one's self and others. Constellations in interactions are approached in slow motion to reveal patterns and needs. As well, the therapist takes specific measures to understand, as best they can, the world from their client's eyes. The therapy is complex, often involving individual, group, and even family elements over 18 months or longer. The results are promising.

MBT originated with a highlight of borderline personality disorder. One study showed improved outcomes up to eight years following treatment, as evidenced by an 87% remission rate (Bateman and Fonagy, 2008). Since, it has been adapted for a range of personality disorders, including antisocial personality disorder and, more recently, narcissistic personality disorder (Drozek and Unruh, 2020). A randomized controlled trial of MBT for individuals diagnosed with both antisocial personality disorder and borderline personality found a reduction in anger and improvement in social outcomes in the group receiving MBT (Bateman et al., 2016) compared to when they received another intervention.

MBT gives reason for hope to individuals seeking recovery from personality disorders.

Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. American Journal of Psychiatry , 165 (5), 631-638.

Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide. Oxford University Press. https://doi.org/10.1093/med:psych/9780199680375.001.0001

Bateman, A., O’Connell, J., Lorenzini, N., Gardner, T., & Fonagy, P. (2016). A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder. BMC psychiatry , 16 , 1-11.

Drozek, R. P., & Unruh, B. T. (2020). Mentalization-based treatment for pathological narcissism. Journal of personality disorders , 34 (Supplement), 177-203.

Jennifer Gerlach, LCSW, is a psychotherapist based in Southern Illinois who specializes in psychosis, mood disorders, and young adult mental health.

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At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

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• Gaslighting
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• 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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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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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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What Is The Prognosis For Narcissistic Personality Disorder? A Review By Doctors

Expert opinion from marcella abunahman pereira, specialization in clinical cardiology · 12 years of experience · brazil.

By definition, the narcissist believes that he or she is superior. Narcissistic personality disorder (NPD) is difficult to treat and resistant to change. Because the behavioral patterns especially with regard to how the person relates to others are difficult to change, the prognosis for NPD is poor. However, if the person is willing to change, with appropriate treatment and corrective life events, such as new achievements and stable relationships, they can lead to considerable improvement.

Expert opinion from Alex T. Thomas

Md · 40 years of experience · usa.

Treatment for Narcissistic Personality Disorder (NPD) is challenging due to the disorder's resistance to change. According to the National Alliance on Mental Illness, those diagnosed with NPD have a terrible prognosis.

Expert opinion from Gustavo Campos

Doctor of medicine · 9 years of experience · brazil.

Like others personality disorders , narcissistic personality disorder may have a less favorable prognosis. Psychotherapy , social support, and other measures may be helpful. However, sometimes they may have improvements by life events.

→ Learn more about narcissistic personality disorder: See the causes, symptoms, treatment options and more.

→ See more questions and expert answers related to narcissistic personality disorder.

Disclaimer: This is for information purpose only, and should not be considered as a substitute for medical expertise. These are opinions from an external panel of individual doctors, and not to be considered as opinion of Microsoft. Please seek professional help regarding any health conditions or concerns.

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

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Gendering Narcissism: Different Roots and Different Routes to Intimate Partner Violence

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• Ava Green   ORCID: orcid.org/0000-0002-4683-0793 1 ,
• Claire M. Hart 2 ,
• Nicholas Day 3 ,
• Rory MacLean 4 &
• Kathy Charles 5  

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Research has only recently begun to explore narcissism in women using gender-inclusive assessments that move beyond traditional male-centric frameworks associated with grandiosity. Such work indicates gender differences in the onset and expression of narcissism, and risk factors of partner violence perpetration. The pathways to offending in narcissism may therefore be gendered but have yet to be tested. In this study, we investigated the mediating role of grandiose and vulnerable narcissism in the association between childhood exposure to maltreatment and later partner violence perpetration in adulthood, and the moderating role of gender in these associations. Participants ( N  = 328) completed scales of grandiose and vulnerable narcissism, perceived parenting styles, and physical/sexual and psychological abuse perpetration. Results indicated gender differences in grandiose (men higher) and vulnerable (women higher) narcissism. Retrospective reports of having mothers who were caring was negatively related to grandiose narcissism for men and vulnerable narcissism for women. Father overprotectiveness was positively related to grandiose narcissism in men. Self-reported vulnerable narcissism was related to greater perpetration of physical/sexual and psychological IPV in women, whereas grandiose narcissism was associated with greater perpetration of psychological IPV in men. For women, but not men, mother care was associated with reduced psychological IPV via lower vulnerable narcissism levels. These findings inform gendered risk markers of narcissism and perpetration of violence for intervention efforts.

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Traditionally, and somewhat expectedly, the narcissism literature has predominantly focused on men, whereas the study of narcissism in women has received comparatively little systematic investigation (Green et al., 2022 ; Grijalva et al., 2014 ). Since its inception, narcissism has been closely associated with the traditional gender socialisation of men due to its core traits of grandiosity as they appear in current clinical diagnostic descriptions (American Psychiatric Association, 2013 ) and ‘gold standard’ assessments in the social/personality literature (e.g., Narcissistic Personality Inventory; NPI; Raskin & Terry, 1988 ). Such prototypical traits include preoccupation with omnipotence, exhibition of self-aggrandizing tendencies, pursuit of power, a sense of entitlement, lack of empathy, interpersonal exploitation, and an authoritarian character style; features which are more strongly present in men than women (Weidmann et al., 2023 ). In the past decade, there has been a surge in empirical literature that recognises the heterogeneity of narcissism, encompassing vulnerable manifestations in addition to grandiosity. In stark contrast to their grandiose counterparts, vulnerable narcissistic individuals display features of inhibition, inadequacy, hypervigilance, shame, low self-esteem, and incompetence (Miller et al., 2011 ). Despite differences in overt features, the two variations of narcissism differ in negative emotionality and agency, but share an antagonistic core (Miller et al., 2021 ; Pincus, 2023 ).

Until recently, theoretical understandings of narcissism in women have been impeded by researchers applying male-coded criteria to women whilst ignoring pronounced gender disparities in the phenotypic expression of this phenomenon (for a review, see Green et al., 2022 ). This pattern occurs despite research demonstrating the vulnerable type of narcissism to be either gender neutral (Grijalva et al., 2014 ; Weidmann et al., 2023 ) or being more prevalent in women (Green et al., 2022 ; Pincus et al., 2009 ; Wright et al., 2010 ). Recent research by Green et al. ( 2020a ) asserted that these gender differences may partially stem from gender-specific trait stereotypes of masculinity and femininity that have been ingrained from early parent-child interactions. In this context, the tendency for men to display more grandiose features and women to display more vulnerable traits may originate from differences in parenting approaches designed to make boys more agentic and girls more communal (Green et al., 2020a ). In line with social role theory (Wood & Eagly, 2012 ), agentic behaviours are more socially adaptive features associated with men, whereas women are likely faced with tougher sanctions when displaying stereotypical features of narcissism. Gendered socialisation practices associated with femininity and masculinity may therefore shape the expression, and preponderance, of vulnerable narcissism in women and grandiose narcissism in men (Green et al., 2020a ).

Theoretical perspectives contend that narcissistic features emerge because of early dysfunctional parent-child interactions (see Horton, 2011 , for a review). Such maladaptive parental practices may include emotional neglect, physical abuse, overprotectiveness, and overindulgent parenting; all of which have been found to contribute to narcissistic disturbances in the child. Indeed, recent meta-analytic findings add to a growing empirical base of studies demonstrating that exposure to childhood maltreatment is a precursor for the development of grandiose and vulnerable narcissism (see Gao et al., 2024 ). In turn, research shows that narcissism is a critical risk factor for violence in adulthood (Ménard et al., 2021 ). For instance, narcissism has been associated with impaired quality of relationships and partner violence perpetration due to the tendency to aggress interpersonally in response to ego-threats, exhibit elevated entitlement to special treatment, lack of empathy, and interpersonal exploitation to achieve own ends (Day et al., 2022b ).

Intimate Partner Violence (IPV) – broadly defined as the perpetration of physical, sexual, and psychological abuse towards an intimate partner – is a serious societal concern that poses significant mental and physical health risks for affected individuals (Day et al., 2019 , 2022a ; Green & Charles, 2019 ; Green et al., 2019 ). Despite concerning figures which estimate 2.9 million men have been a victim of domestic violence since the age of 16 (Home Office, 2022 ), surprisingly little is known about the antecedents of violence perpetrated by narcissistic women. While intimate partner violence is perpetrated predominately by men (Home Office, 2022 ), without considering the contributing role of narcissism (and particularly vulnerable narcissism), instances of perpetration by women may be missed as it does not correspond with the archetype of a ‘typical’ abuser. Therefore, there is a need to expand our understanding of risk markers of IPV to include those of women with salient features of vulnerable narcissism, in order to improve identification, prevention and intervention efforts.

The present study aims to enhance theory and inform practice regarding the extent to which grandiose and vulnerable narcissism mediate the association between childhood exposure to maltreatment and subsequent partner violence in adulthood, and the moderating role of gender in these associations.

Gender Differences in the Development of Narcissism

The emergence of narcissistic features in adulthood have been largely attributed to environmental factors. Early theorists have ascribed adverse parenting to the development of narcissistic personality traits, specifically referring to neglectful (Kohut, 1977 ), combined with overprotective (i.e., intrusiveness and controllingness; Kernberg, 1975 ), and overindulgent (Millon, 1981 ) parenting. Although empirical examinations into narcissism and childhood experiences have been widely studied, the literature has yielded inconclusive results due to assessments of narcissism (NPI) as a unidimensional concept and singular or multiple assessments of different parenting styles being utilised (for a review, see Kılıçkaya et al., 2023 ). More recently, research has provided a clearer picture regarding the aetiology of narcissism by considering the gendered pathways in the emergence of grandiose and vulnerable features. For example, Mechanic and Barry ( 2015 ) found that recalled perceptions of inconsistent parental discipline predicted unique variance in vulnerable narcissism, with a main effect also present for gender (i.e., women scoring higher). Similarly, Ensink et al. ( 2017 ) demonstrated that recalled parental neglect and psychological abuse was positively associated with vulnerable and grandiose narcissism in girls.

Taking into consideration parent gender, Cramer ( 2015 ) found that a mother’s parenting practice was associated with vulnerable narcissism and a father’s parenting practice was related to grandiose narcissism. Recollections of parental permissiveness and responsiveness by both mothers and fathers were negatively associated with grandiose and vulnerable narcissism, whereas authoritarian parenting by both mothers and fathers were positively associated with both forms of narcissism. Although this study consisted of a small sample ( n  = 85), other studies also confer these findings. For instance, Huxley and Bizumic ( 2017 ) reported that remembered maternal invalidation positively predicted vulnerable narcissism for participants who experienced low to medium levels of paternal invalidation, while higher levels of paternal invalidation positively predicted grandiose narcissism.

Recent work by Green et al. ( 2020a ) provides further empirical support for the parenting styles theoretically associated with the aetiology of narcissism across gender, through an exploration of recalled neglectful (Kohut, 1977 ), overprotective (Kernberg, 1975 ), and indulgent parenting (Millon, 1981 ) by mothers and fathers. Findings revealed that recalled paternal overprotectiveness positively predicted grandiose and vulnerable narcissism in men, whereas recalled accounts of maternal warmth negatively predicted vulnerable narcissism in women in adulthood. On the one hand, these etiological disparities may indicate differences in the conceptual core of narcissism as proposed by early theorists. For instance, Kernberg ( 1975 ) conceived narcissism as centred on grandiosity and aggression, whereas Kohut’s ( 1977 ) formulation focused on vulnerability and shame. On the other hand, the observed gendered parenting by mothers and fathers may implicate internalisation of stereotyped behaviour which shapes vulnerable narcissistic features in women and grandiose narcissistic features in men. Overall, emergent research in the literature denotes that the onset of narcissism has different developmental antecedents in men and women.

Gender Differences in Intimate Partner Violence Perpetration

The association between narcissism and violence is well-documented in both clinical and community samples (Bogaerts et al., 2021 ; Bushman, 2017 ; Day et al., 2022b ; Fatfouta et al., 2015 ; Green & Charles, 2019 ; Hepper et al., 2014 ; Johnson et al., 2000 ; Kalemi et al., 2019 ; Krusemark et al., 2018 ). Theoretically, the link between narcissism and violence has been commonly explained in terms of ‘threatened egotism’ in the social/personality literature (Baumeister et al., 2000 ) and ‘narcissistic injury’ in the clinical field (Freud, 1914/1957 ; Kohut, 1977 ; Logan, 2009 ). According to both models, narcissistic individuals retaliate with rageful and aggressive behaviours in response to perceived threats towards their self-image, as an attempt to (dys)regulate intolerable emotions, such as shame and humiliation. Empirical support for these theories has, however, been largely based on male samples (Barry et al., 2015 ; Baumeister et al., 2000 ; Bogaerts et al., 2021 ; Bushman, 2017 ; Bushman et al., 2003 ; Krusemark et al., 2018 ; Lobbestael et al., 2014 ; Mouilso & Calhoun, 2016 ; Palermo, 2008 ; Velotti et al., 2020 ). The literature consequently narrates the profile of a narcissistic offender which closely mirrors a hostile masculine personality, where the aggressor reacts with hostility towards perceived insults to his profound sense of self-worth and superiority, which has wounded his pride and masculinity (Baumeister et al., 2000 ; Mouliso & Calhoun, 2016).

A similar trend has been indicated in the IPV literature, where women are excluded entirely due to the long prevailing belief that men are more narcissistic and aggressive than women (e.g., Buck et al., 2014 ; Meier, 2004 ; Rinker, 2009 ; Talbot et al., 2015 ). Whilst narcissism and IPV perpetration have been positively linked to both genders, the few studies which include women ignore gender differences in the personality construct. For example, Blinkhorn et al. ( 2015 , 2016 , 2018 ) claim to extend the literature on narcissism in female offenders whilst utilising grandiose narcissism (NPI) as their main assessment, thereby invoking the belief or implicitly assuming that the male template can be transferable to women (see also Caiozzo at al., 2016; Gormley & Lopez, 2010 ; Hughes et al., 2020 Lamkin et al., 2017 ; March et al., 2020 ; Sharma, 2021 ). These studies have not considered a gender-equivalent assessment that includes vulnerable features of narcissism, despite frequent indications in the literature suggesting that the outward expression of narcissism differs in women (Campbell & Miller, 2011 ; Grijalva et al., 2014 ; Morf & Rhodewalt, 2001 ; Philipson, 1985 ; Pincus et al., 2009 ; Richman & Flaherty, 1988 ; Wright et al., 2010 ).

The sparse literature that employs gender-appropriate assessments indicate that female aggression and violence are expressed in more subtle and coercive forms, compared to male violence that is more overt and grandiose in nature. Dyadic research conducted by Ryan et al. ( 2008 ) found that, in women only, the exploitative/entitlement facet of grandiose narcissism, which significantly correlated with vulnerable narcissism, was related to sexual coercion. These findings were interpreted as narcissistic women being more hypersensitive to the perceived coercive behaviours of their partners, consequently exerting manipulative strategies to gain control in their relationship. Similarly, Southard ( 2010 ) found that, compared to men, vulnerable narcissism and the exploitative/entitlement facet were only related to women’s use of specific manipulative tactics such as bullying and disengagement. Related research finds that both grandiose and vulnerable features in both genders were significantly linked to their perpetration of psychological abuse in intimate relationships (Ponti et al., 2020 ), whereas other research finds vulnerable narcissism as a significant predictor of cyber intimate partner violence in women (Branson & March, 2021 ; March et al., 2020b ), but not in men (March et al., 2020 ). Each of these studies are, however, limited in exploring only certain tactics of IPV as opposed to the full spectrum (physical/sexual, and psychological abuse).

A novel qualitative study by Green et al. ( 2019 ) enhanced theoretical knowledge regarding narcissism in women and attempts at self-regulation within the full spectrum of IPV. Results showed that gender-related norms shaped motives for women to self-regulate in ego-threatening situations. These strategies were perceived to be obtained through exploiting their feminine qualities (e.g., playing the ‘mother card’, adopting the ‘victim status’) and using legal and societal benefits to assert their dominance over their partner. Essentially, their ‘mask of femininity’ was perceived to resemble features of vulnerable narcissism by intimate partners. Extending these findings in a more comprehensive quantitative study, Green et al. ( 2020b ) found that vulnerable narcissism, but not grandiose narcissism, was the only significant predictor of women’s perpetration of physical/sexual and psychological abuse on a partner. In men, grandiose narcissism predicted psychological abuse and vulnerable narcissism predicted physical/sexual abuse perpetration. These findings support previous speculations that women use more strategic attempts to achieve their narcissistic goals than men, which are not recognised as ‘stereotypically’ narcissistic (Campbell & Miller, 2011 ; Morf & Rhodewalt, 2001 ). Thus, the observed gender-specific motives for perpetrating violence in narcissistic individuals may reflect gendered pathways to violence.

Childhood Maltreatment and Subsequent Violence: The Mediating Role of Narcissism

Research shows that those exposed to abuse and adverse parenting practices during childhood are at increased risk of committing violence in adulthood (Ménard et al., 2021 ). However, there are factors which may mediate this link, given that not all children who are victimised subsequently become violent themselves. Previous research has shown that personality disorders can mediate associations between exposure to childhood maltreatment and later violence, however the literature falls short of sufficiently evaluating the role of narcissism (Brennan, 2014 ). For instance, Kalemi et al. ( 2019 ) reported that narcissism (using the NPI only) and a history of child abuse significantly predicted aggression in a sample of female inmates; however, the study failed to assess the mediating role of narcissism along with the inclusion of vulnerable narcissism. Similarly, Plouffe et al. ( 2022 ) explored only grandiose narcissism (as part of the ‘dark triad’ constellation), physical partner violence and a history of early adverse experiences, however, failed to conduct mediation analyses as the relationship between childhood maltreatment and later physical partner violence was non-significant. Including both grandiose and vulnerable narcissism in the evaluation of childhood abuse and subsequent physical partner violence, Ménard et al. ( 2021 ) found that neither narcissistic component was found to mediate this relationship. Lastly, Brennan ( 2014 ) employed the Pathological Narcissism Inventory (PNI) and found that narcissism partially mediated the link between exposure to child abuse and subsequent general violence in adulthood. Important limitations to note here concerns the operationalisation of narcissism and violence which were treated as unitary assessments, thus gender variations in grandiose and vulnerable narcissism were not explored along with different tactics of violence.

Current Study

As the preceding review of the literature has demonstrated, there is only a nascent literature on narcissism in women using gender-inclusive assessments. This research suggests that the antecedents of narcissism and motives for perpetrating partner violence are differently expressed in women and men, inviting the assumption that there are gendered pathways to offending behaviour that require appropriate interventions. This novel study aims to investigate the mediating role of grandiose and vulnerable narcissism in the association between exposure to childhood adversity and subsequent partner violence, taking into consideration gender differences in these patterns (see theoretical model shown in Fig.  1 ). Based on previous research, we propose the following hypotheses:

Hypothesised model

We expect gender differences in narcissism where men score significantly higher in grandiose narcissism than women, and women score significantly higher on vulnerable narcissism than men. This hypothesis is based on the observed longstanding gender differences in narcissism found in past research (e.g., Green et al., 2022 ; Grijalva et al., 2014 ).

We expect conditional direct effects of retrospective recall of parenting style on self-reported narcissism and IPV perpetration. Specifically, for women , we predict neglectful parenting (lack of care) by the mother will be positively associated with vulnerable narcissism (2a) and later partner violence (2b), for vulnerable narcissism to be positively associated with IPV (2c), and for vulnerable narcissism to mediate the relationship between parenting and IPV (2d; conditional indirect effect). This prediction is based on Kohut’s ( 1977 ) theorised parenting style and prior research finding an association between lack of maternal care and vulnerable narcissism in women (Green et al., 2020a ), and the link between vulnerable narcissism and IPV in women (e.g., Branson & March, 2021 ; Green et al., 2019 , 2020b ; March et al., 2020 ; Ponti et al., 2020 ).

We also predict that for men , overprotective parenting by the father will be positively associated with grandiose narcissism (3a) and later partner violence (3b), for grandiose narcissism to be positively associated with IPV (3c), and for grandiose narcissism to mediate the relationship between parenting and IPV (3d; conditional indirect effect). This hypothesis is based on Kernberg’s ( 1975 ) theorised parenting style and previous research demonstrating an association between overprotective parenting and grandiose narcissism in men (Green et al., 2020a ), and the link between grandiose narcissism and IPV in men (e.g., Green et al., 2020b ; Meier, 2004 ; Mouilso & Calhoun, 2016 ; Rinker, 2009 ).

Participants

Power analysis software (G*Power 3.1.9.2; Faul et al., 2007 ) was used to calculate minimum sample size to achieve a desired moderate effect size ( f 2 = 0.15) at p  < .05 significance level using a multiple regression with 19 predictor variables with 80% power: recalled care and overprotective parenting by mother and father (4), participant gender (1), grandiose and vulnerable narcissism (2), and all combinations of parenting*gender (8) and narcissism*gender interactions (4). Power analysis stipulates a minimum of 153 participants is required to achieve a power of 0.80.

From the initial sample pool ( n  = 704), 371 participants were excluded due to incomplete data. Of those who completed the study ( n  = 333), five participants were eliminated because they did not identify as any gender ( n  = 3), were under 18 years old ( n  = 1), and they did not give informed consent ( n  = 1). The final analysis was conducted using the remaining 328 participants. The sample comprised 176 (53.7%) women and 152 (46.3%) men. The age range of the participants was 18–64 years with a mean of 27.93 years ( SD  = 9.09). Relationship status and duration, and stated sexuality, broken down by gender, is displayed in Table  1 . The sample was predominantly White ( n  = 262), with 16 South or East Asian, 12 Hispanic or Latino, 10 African, and five Middle Eastern; the remaining 23 participants chose ‘mixed’ or ‘other’ for their ethnic status.

Pathological Narcissism Inventory

The Pathological Narcissism Inventory (PNI; Pincus et al., 2009 ) is a 52-item self-report measure of pathological narcissism that assesses both vulnerable (34 items) and grandiose (18 items) features. Responses to the 52-items are made on a 6-point Likert-type scale ranging from 0 ( not at all like me ) to 5 ( very much like me ). Seven primary scales of the PNI load on to two higher order domains of Narcissistic Grandiosity and Narcissistic Vulnerability. The scales that load on to Narcissistic Grandiosity include Exploitativeness, Grandiose Fantasy, and Self-Sacrificing Self-Enhancement; and the scales that load on to Narcissistic Vulnerability include Contingent Self-Esteem, Hiding the Self, Devaluing, and Entitlement Rage. Because each subscale varies in scale length, mean item endorsements are used instead of sums to enable ease of comparison across scales (Pincus et al., 2009 ). The PNI is a widely used measure and manifests good internal consistency (Pincus et al., 2009 ). In the present study, Cronbach’s alpha for the grandiose component was α = 0.87 and α = 0.95 for the vulnerable component.

Conflict Tactics Scale Short Form

The Conflict Tactics Scale short form (CTS2S; Straus & Douglas, 2004 ) is a revised 20-item measure of IPV adapted from the longer 39-item measure version of the CTS2. The scale measures perpetration of physical/sexual abuse as well as whether participants have been a victim of violent tactics by their partner. We only focused on the 10-items pertaining to perpetration in this study. The CTS2S uses an 8-point frequency scale to focus on tactics (Negotiation, Psychological Aggression, Sexual Coercion, Physical Assault, and Injury) used during conflict within intimate relationships (0 =  this never happened to 8 =  this happened more than 20 times in the past ). In the current study, in line with Straus and Douglas’ coding scheme, participants were asked to report the occurrence of any violence perpetrated during the course of their relationship, or asked to recall any instances from their most recent relationship. A score of “1” was awarded if one or more acts of violence for each of the tactics during the course of the relationship had occurred and a score of “0” was awarded when no instances of violence were reported. Total ratings were computed for perpetration scores by summing the zeros and ones across the different traits. The CTS2S has demonstrated good construct and concurrent validity (Straus & Douglas, 2004 ). In the present study, perpetrator reliability was α = 0.69, which is marginally below the proposed cut-off of acceptable internal consistency of 0.70 (Cronbach, 1951 ). In addition, given that the CTS2S is not designed to sample psychological aggression in depth, it was decided to measure psychological abuse separately.

Multidimensional Measure of Emotional Abuse

The Multidimensional Measure of Emotional Abuse (MMEA; Murphy & Hoover, 1999 ) is a 28-item scale that specifically measures the psychologically abusive aspect of IPV. Subscales for this questionnaire include Restrictive Engulfment, Denigration, Hostile Withdrawal, and Dominance Intimidation. As with the CTS2S, the MMEA uses an 8-point frequency scale to measure the number of times a particular aspect of emotional abuse has occurred within a relationship. In the current study, participants were asked to report the occurrence of any psychological abuse perpetrated during their relationship or asked to recall any instances from their most recent relationship. The same scoring scale used for CTS2S was adopted for the MMEA inventory to ensure consistent scoring method of prevalence across the IPV questionnaires. The MMEA questionnaire is statistically valid as an index of psychological aggression for research purposes (Murphy & Hoover, 1999 ). In the present study, internal reliability for perpetration was α = 0.89. Both the MMEA and CTS2S have been utilised in previous research on narcissism and IPV (Carton & Egan, 2017 ; Green et al., 2020b ).

Parenting Bonding Instrument

The Parenting Bonding Instrument (PBI; Parker et al., 1979 ) measures recollections of parental care (e.g., “He/She was affectionate to me;” “He/She tended to baby me”) and overprotectiveness (e.g., “He/She invaded my privacy;” “He/She tried to control everything I did”). The scale has 12 items reserved for the mother (or female caregiver) and 12 items for the father (or male caregiver). Participants were asked to recall the parenting styles of their parents (or parental figures) during their first 16 years of life on a 4-point rating scale: 1 ( very like her/him ) to 4 ( very unlike her/him ). The 12 items for maternal parenting and 12 items for the paternal parenting were totalled to create corresponding indexes. The PBI shows good internal consistency and has been used in previous narcissism research (e.g., Maxwell & Huprich, 2014 ). In the present study, internal reliability for the total PBI score was α = 0.80.

Ethical approval was granted by Edinburgh Napier University School of Applied Sciences Research Integrity Committee. Participants were invited to take part in a study titled “Personality traits and intimate relationships,” which was advertised online on various social media platforms (Facebook, Twitter, Reddit) and research participation websites (psychological research on net), as well as flyers shared at gym facilities which contained a QR code that when scanned, directed participants to the online survey hosted by Qualtrics. Inclusion criteria included being over 18 years of age, being fluent in English, providing informed consent, and experience of being in a relationship. Participants provided informed consent by clicking a box before beginning the survey. They first completed demographic questions and then continued to complete the PNI, CTS2S, MMEA, and the PBI questionnaires, which were presented in that order for each participant. On completion, participants were given the option to enter a draw for a chance to win a £50 Amazon gift voucher. Participants were then directed to the debrief page, thanked, and presented with a list of support networks associated with IPV. Overall, the study took approximately 15–30 min to complete.

Preliminary Analysis

MCAR tests were used to test if missing data were random, and revealed that for the PBI, data were not missing at random; therefore, the mode was used to replace missing data values. Replacing values using the mode is a standard and basic imputation method and, compared to the mean substitution method, does not reduce variance in the dataset (Baraldi & Enders, 2010 ). All other variables did not show non-random missing data.

Table  2 presents descriptive statistics and Table  3 presents zero-order correlations for the key study variables broken down by gender. Independent samples t-tests (see Table  2 ) were conducted to test gender differences across all variables for completeness, though we did not have specific predictions for mean gender differences in the study variables, except for the narcissism variables. For parenting style variables, the findings revealed significant gender differences in recall of parental upbringing and exposure to mother care (higher for men), mother overprotectiveness (higher for women), father care (higher for men), and father overprotectiveness (higher for women). For the IPV variables, women reported significantly higher levels of perpetration of physical/sexual abuse and psychological abuse in our sample. There was no significant difference in the length of time the men and women in our sample had been in their current relationship. For our prediction for the narcissism variables, there was no significant gender difference in grandiose narcissism; however, women reported higher levels of vulnerable narcissism compared to men, providing partial support for Hypothesis 1.

Zero-order correlations (Table  3 ) revealed that for both men and women, there was a negative association between recalled mother and father care and participants’ scores of grandiose and vulnerable narcissism. Mother and father care were also negatively associated with perpetration of physical/sexual and psychological abuse for both men and women. For both men and women, there was a positive association between recalled mother and father overprotectiveness and grandiose and vulnerable narcissism. Mother and father overprotectiveness were positively associated with perpetration of physical/sexual and psychological abuse for both men and women.

As in previous research, grandiose and vulnerable narcissism were positively associated with each other among men and women. Grandiose narcissism was positively associated with psychological, but not physical/sexual, IPV for men, whereas grandiose narcissism was positively associated with both types of IPV for women. Vulnerable narcissism was positively associated with both types of IPV for both men and women.

Finally, relationship duration was negatively associated with vulnerable and grandiose narcissism for women and with grandiose narcissism for men. Relationship duration was thus controlled for in subsequent analyses.

Moderated Mediation

To test Hypotheses 2 and 3, we used PROCESS Version 4.1 to test moderated mediation models (Hayes, 2017 ; Model 59). We tested whether retrospective reports of mother and father parenting (predictor variables) were associated with grandiose and vulnerable narcissism (mediator variables) and whether retrospective parenting and narcissism were associated with perpetration of two types of IPV: physical/sexual and psychological (outcome variables). We examined all parenting variables simultaneously to allow us to covary out the potential shared variance in exposure to the different parenting styles of both parents. Relationship duration was also included as a covariate. We examined whether all of these relationships were moderated by participant gender (moderating variable).

PROCESS only allows one predictor variable to be entered at a time but can estimate a model with multiple predictor variables by adding these as covariates in the model (Hayes, 2017 ). Our model had four predictor variables (retrospective reports of mother and father’s care and overprotectiveness). To estimate the direct and indirect effects of the target predictor variable, four models were run for each of the outcome variables. Mathematically, all resulting paths are equivalent to having entered them simultaneously in a structural equation model (Hayes, 2017 ). All models were run with 10,000 bootstraps. All continuous predictor variables (parenting variables, grandiose and vulnerable narcissism) were centred prior to analysis. Gender was dummy coded such that men = 0 and women = 1. Accordingly, the conditional direct effects reported below use men as the reference group.

Perpetrator Physical/Sexual IPV

Conditional direct effects and interactions are presented in Table  4 . Effects broken down by gender and conditional indirect effects are presented in Table  5 .

Retrospective Parenting Style and Gender on Narcissism The betas in Table  4 represent the estimated difference in narcissism scores between two people who differ by one unit in gender amongst those who score at the grand mean on parenting. Across all parenting models (mother and father care and overprotectiveness), gender (with men coded as 0 and women coded as 1) was negatively associated with grandiose narcissism and positively associated with vulnerable narcissism, indicating that men score higher on grandiose narcissism than women and women score higher on vulnerable narcissism than men.

Mother care was negatively associated with grandiose narcissism (when gender = 0) whilst father overprotectiveness was positively associated with participants’ grandiose narcissism.

Narcissism on IPV Across all parenting models, neither grandiose nor vulnerable narcissism was a significant predictor of physical/sexual IPV for men. Table  5 shows that for women, vulnerable narcissism was positively and significantly associated with physical/sexual IPV. For men these effects were also positive but non-significant. Note, however, that the interaction term between vulnerable narcissism and gender across models was non-significant.

Retrospective Parenting Style on IPV Mother care was negatively associated with physical/sexual IPV for men. Mother care was also negatively associated with physical/sexual IPV for women, although this failed to reach statistical significance. The interaction between retrospective reports of mother care and gender was non-significant.

Father overprotectiveness was positively associated with physical/sexual IPV for men. The effect was also positive and significant for women. The interaction term between father overprotectiveness and gender was non-significant.

Indirect Effects of Parenting on IPV via Narcissism Results are presented in Table  5 . A significant indirect effect of mother care on physical/sexual IPV via vulnerable narcissism emerged; mother care was negatively associated with vulnerable narcissism and vulnerable narcissism was positively associated with psychological IPV. Mother care thus acted as a buffer against IPV via lower vulnerable narcissism levels. There was no significant indirect effect for men. Note, however that the index of moderated mediation for each model was non-significant, therefore the indirect effects were not related to gender across our models.

We present the above significant results in diagrammatic form in Fig.  2 .

Significant gendered paths between parenting, narcissism, and physical/sexual IPV. Note Solid lines represent significant pathways for male participants. Dashed lines represent significant pathways for female participants

Perpetrator Psychological IPV

The same model was tested with psychological IPV as the outcome variable. Conditional direct effects and interactions are presented in Table  6 . Effects broken down by gender and conditional indirect effects are presented in Table  7 .

Retrospective Parenting Style and Gender on Narcissism The betas in Table  6 represent the estimated difference in narcissism scores between two people who differ by one unit in gender amongst those who score at the grand mean on parenting. Across all parenting models (mother and father care and overprotectiveness), gender (with men coded as 0 and women coded as 1) was negatively associated with grandiose narcissism and positively associated with vulnerable narcissism, indicating that men score higher on grandiose narcissism than women and women score higher on vulnerable narcissism than men. Mother care was negatively associated with grandiose narcissism (when gender = 0) and father overprotectiveness was positively associated with participants’ grandiose narcissism.

Narcissism on IPV Across all models, grandiose narcissism was a positive predictor of psychological IPV (when gender = 0). With the exception of the father care parenting model, significant interactions between vulnerable narcissism and gender also emerged (see Table  7 ). In all cases, there was a positive association between vulnerable narcissism and IPV for men and women, but these relationships only reached significance for women.

Retrospective Parenting Style on IPV Mother care was negatively associated with psychological IPV for men. Mother care was also negatively associated with psychological IPV for women, although this failed to reach statistical significance. The interaction between retrospective reports of mother care and gender was non-significant.

Father overprotectiveness was positively associated with physical IPV for men. The effect was also positive albeit non-significant for women. The interaction term between father overprotectiveness and gender was non-significant.

Indirect Effects of Parenting on IPV via Narcissism As presented in Table  7 , the index of moderated mediation was significant for mother care. That is, for women only there was a significant indirect effect of mother care on psychological IPV via vulnerable narcissism; mother care was negatively associated with vulnerable narcissism and vulnerable narcissism was positively associated with psychological IPV. Mother care thus acted as a buffer against IPV via lower vulnerable narcissism levels. There was no significant indirect effect for men.

The index of moderated mediation values for all other models were non-significant, therefore the indirect effects were not related to gender across these models.

We present the above significant results in diagrammatic form in Fig.  3 .

Significant gendered paths between parenting, narcissism, and psychological IPV. Note Solid lines represent significant pathways for men. Dashed lines represent significant pathways for women

The present study sought to investigate the mediating role of grandiose and vulnerable narcissism in the relationship between recalled parenting practices in childhood and perpetration of partner violence in adulthood, and the extent to which gender moderates these associations. This area is worthy of investigation due to the need for a tailored approach to address risk markers of violence against men by women, which is currently overshadowed by dominant perspectives of male perpetration of violence.

Gender Differences

In line with Hypothesis 1, independent t-tests revealed significant gender differences in mean levels of vulnerable narcissism only (with higher scores for women than men) but no significant difference in levels of grandiose narcissism between men and women. However, all moderated mediation models (which partialled out the effects of the other type of narcissism within the models) revealed gender differences, such that men scored higher on grandiose narcissism than women and women scored higher in vulnerable narcissism than men. These findings are congruent with the vast literature reporting consistent gender disparities in narcissism facets (Green et al., 2020a , b , 2022 ; Grijalva et al., 2014 ; Pincus et al., 2009 ; Weidmann et al., 2023 ; Wright et al., 2010 ). As previously theorised, prototypical expressions of narcissism in men and women may be partly symptomatic of prescribed sociocultural norms along masculine and feminine lines (Wood & Eagly, 2012 ). The tendency for women to align more closely with narcissistic vulnerability and for men to exhibit overt grandiosity may indicate the conformity of such behaviours with cultural gender roles that resemble stereotypical characteristics of women (e.g., low self-esteem, shame, hypersensitivity, neuroticism) and men (e.g., inflated self-image, assertiveness, authority, superiority; Green et al., 2022 ).

Gendered Roots

Results further revealed significant gender differences when exploring different paths within the models. For the zero-order correlations, recollections of an overprotective parent (mother or father) were positively associated with the development of both forms of narcissism across gender. These results are in concordance with the ideas espoused by Kohut ( 1977 ) and Kernberg ( 1975 ) who implicated the development of narcissistic features as the result of cold and overprotective parenting, respectively, and in line with past empirical findings (Ensink et al., 2017 ; Green et al., 2020a ; Huxley & Bizumic, 2017 ). Supporting Hypothesis 2a, retrospective accounts of a caring mother were negatively associated with vulnerable narcissism in women, in line with prior research (Green et al., 2020a ), as well as to grandiose narcissism in men. In addition to specific parenting tactics, our findings support the contention that expressions of grandiosity and vulnerability in men and women may be further influenced by the gender of the parent. When controlling for shared variance for all variables, we found that recalled paternal overprotectiveness was associated with higher levels of self-reported grandiose narcissism in men only, consistent with Hypothesis 3a and previous findings (Green et al., 2020a ).

Accordingly, mothers and fathers may reinforce stereotyped gendered behaviours associated with agentic behaviours, such as assertiveness and grandiose fantasies in boys, whereas girls are more likely to internalise communal features associated with vulnerability and hypersensitivity (Wood & Eagly, 2012 ). This might be a reason why paternal overprotectiveness was a significant predictor of grandiose narcissism, but not vulnerable narcissism, in men. These findings may suggest that men have a more complex relationship in their recollections of early life experiences with their fathers, and/or that a father’s role may be more central to their development of (grandiose) narcissism than their mother’s role. Although the self-report methodology precludes substantial confidence in this conclusion, it is nevertheless a possibility that lends itself to further exploration, and, more importantly, underscores the importance of including reports of both parents in future research. This is particularly in light of, and contrary to, the gendered vocabulary articulated (i.e., referring to the parent as mother) when discussing narcissistic development between the child and primary care giver (Freud, 1914/1957 ; Phillipson, 1982; see Horton, 2011 , for an overview).

Gendered Routes

As for associations with partner violence perpetration at the bivariate level, our results showed that both forms of narcissism were positively significantly associated with physical/sexual and psychological perpetration towards an intimate partner in women. In men, only grandiose features were positively significantly associated with psychological perpetration (consistent with Hypothesis 3c) whereas vulnerable features were positively significantly correlated with all forms of IPV perpetration (consistent with Hypothesis 2c). This was unsurprising given past empirical findings linking narcissism facets to IPV (see Green et al., 2022 , for a review), and contributes further theoretical support for the ‘narcissistic injury’ premise (Baumeister et al., 2000 ; Freud, 1914/1957 ; Kohut, 1977 ; Logan, 2009 ). When accounting for shared variance for all other variables, results revealed gender-specific routes to IPV. Here, grandiose narcissism was found to be the only significant predictor of psychological IPV for men, whereas vulnerable narcissism was the only significant predictor of psychological IPV perpetration in women. The need for some men to maintain a grandiose self-image, engage in self-sacrificing self-enhancement attitudes and an exploitative interpersonal style is associated with a greater likelihood of subjecting partners to psychologically abusive tactics. These findings resonate with previous research that found a positive association between grandiose narcissism and the perpetration of psychological abuse (Caiozzo et al., 2016 ; Carton & Egan, 2017 ; Gormley & Lopez, 2010 ; Green et al., 2020b ; Peterson & DeHart, 2014 ; Rinker, 2009 ).

In contrast, and in line with past empirical literature (Branson & March, 2021 ; Green et al., 2019 , 2020b ; March et al., 2020b ; Ponti et al., 2020 ), women’s tendency to express the more covert and feminine-typed traits of narcissism (e.g., hiding the self, fluctuation in self-esteem, rejection sensitivity, devaluation, shame over unmet needs) cultivates a sense of narcissistic entitlement to psychologically abuse intimate partners. As these attributes diverge from the overt masculine-stereotyped traits that comprise grandiose narcissism typically viewed in men, risk markers of narcissism and violence in women may be overlooked given outward expressions of shyness, sensitivity, and insecurity. Thus, the evaluation of narcissism and violence in women is important for theoretical and practical reasons, as self-regulatory motives to obtain power and dominance within interpersonal context appear gender specific. These results arguably significantly limit the generalisability and applicability of research which conceptualises women’s narcissism using male-criteria (e.g., Blinkhorn et al., 2015 , 2016 , 2018 ; Caiozzo at al., 2016; Gormley & Lopez, 2010 ; Hughes et al., 2020 ; Lamkin et al., 2017 ; March et al., 2020 ; Sharma, 2021 ).

Furthermore, we expected lack of maternal care to significantly predict later partner violence in women (Hypothesis 2b), with vulnerable narcissism mediating this relationship (Hypothesis 2d). Whilst we found no direct effect of maternal care on either type of IPV in women, we did find significant indirect effects: retrospective accounts of a caring mother negatively predicted vulnerable narcissism which was, in turn, indirectly associated with lower instances of psychological abuse towards a partner. It is not surprising that recalled memories of a warm and nurturing mother during childhood fosters an independent self-regard and healthy development of the child’s personality, which in turn leads to more stable adult relationships. We also surmised that lack of paternal overprotectiveness would positively predict IPV in men (Hypothesis 3b), with grandiose narcissism mediating this relationship (Hypothesis 3d). Although we found significant direct effects of paternal overprotectiveness on both forms of IPV, we did not find significant indirect effects, despite the gendered pathways being in the expected directions: for men only, paternal overprotectiveness significantly predicted grandiose narcissism, and grandiose narcissism was positively associated with psychological IPV.

Overall, the current results show gendered roots in the manifestation of narcissism and gendered routes to IPV perpetration. In women only, one novel finding emerged which revealed that recalled maternal care acted as a buffer against IPV via lower vulnerable narcissism levels. These findings stress the need for gender-inclusive interventions to address risk factors in narcissism and IPV perpetration.

Limitations and Future Research Directions

There are several limitations with the current study. For example, data relied on retrospective reports of childhood experiences, thus the possibility that the findings reflect differences in recollection rather than differences in original childhood experience must be acknowledged. However, to do so conclusively would require much more extensive longitudinal research with multiple measures gathered from children’s perspectives of their parent’s parenting practices, along with their parent’s own perspectives on their child-rearing practices. Another issue with retrospective reports in general, and in narcissism research especially, is their propensity to introduce bias in reconstructive memory processes (Morf & Rhodewalt, 2001 ). Although bias may be present to some extent, childhood recollections provide an important and well-validated first line of evidence into adult consequences of childhood experiences (Chipman et al., 2000 ). Moreover, potential parent-child interactions could not be directly investigated in the current study, thus the possibility cannot be ruled out that the direction of causality may be either bidirectional or reversed. This is a potential avenue for future research to explore, particularly considering that some research indicates discrepancies exist between parents and adolescents’ views of parenting behaviours assessed (Mechanic & Barry, 2015 ).

It is also important to note that, whilst clinical theories suggest narcissism emerges as a result of the parent’s narcissistic use of the child, research has found that narcissism is a moderately heritable personality trait and is partly rooted in early emerging temperamental traits (Vernon et al., 2008 ). Therefore, some children, because of their temperamental traits, might be more likely than others to become narcissistic when exposed to certain environmental stimuli (Miles & Francis, 2014 ; Thomaes et al., 2009 ). Future research should study longitudinally the bidirectional association between parenting and adolescent narcissism via genetic influences on parenting as this may account for child characteristics, which could elicit certain parental responses (see Ayoub et al., 2018 ; also see Klahr & Burt, 2014 ).

A further limitation pertains to the physical/sexual abuse inventory (CTS2S; Straus & Douglas, 2004 ) which captures sexual aggression with only two items. It is recommended that future research use a more robust measurement that captures these elements in more depth. Future research should also consider exploring narcissism and IPV in dyadic relationships, and how different sexual orientations and IPV bidirectionality impact gendered expressions of narcissism. It is also worth noting that the items captured by the CTS2S may be skewed towards men and thus do not capture the ways in which women enact physical/sexual IPV. The influence of gendered socialisation and gender norms may have further impacted the (under)reporting and (mis)interpretation of female perpetrated IPV. In other words, women in the current study may be less inclined to admit to overt physical and sexual violence as such acts go against long-grained stereotyped expectations of their feminine gender identity.

Considering the speculations pertaining to gendered parenting in the development of narcissism, future research could also conduct further analysis to examine whether current results are replicated across different family structures (single parent, same-sex parent families) and gender-specific processes. Moreover, research undertaken with parents demonstrates associations between grandiose narcissism and an increased propensity towards non-optimal parenting styles (authoritarian and permissive), with low empathy predicting unresponsive caregiving towards a child (Hart et al., 2017 ). Given the detrimental ramifications dysfunctional parenting could have on the development of the child, future research could extend these findings to parents with both grandiose and vulnerable narcissism traits, whilst including the role of empathy to assist in the development of effective interventions (see Hart et al., 2017 ).

Practical Implications

The current findings stress the importance of early parent-child interaction therapy and interventions aimed at reinforcing positive parenting styles and child-rearing environments to ensure healthy attachment in the child and prosocial behaviour. However, notwithstanding the importance of early intervention efforts, the clinical reality is that most patients attend to treatment as adults once these early experiences are entrenched as part of a wider constellation of personality pathology. It is for this reason that contemporary evidence-based treatments for personality disorder pay close attention to the remembered early childhood experiences of adult patients in order to understand an individual’s psychological building blocks – this includes concepts such as the ‘invalidating environment’ of dialectical behaviour therapy (Linehan, 2015 ), or ‘internalised object relations’ as related to early parent-child interactions for transference focused psychotherapy (Clarkin et al., 2006 ). These remembered experiences are important for understanding the aetiology of personality pathology, but more importantly also for how such themes are also still active within the patient’s life in the here and now when it comes to areas of intrapersonal and interpersonal difficulty.

Based on the findings of this study, when working with men with elevated narcissistic features there may be a need to attend to current themes of ‘overprotectiveness’ (e.g., intrusiveness, dominance) that they experience from others in their everyday life (and even directly with the therapist). This needs to be explored, including the resulting emotional reactions (e.g., hostility, resentment), potential links with defensive reactions such as superiority and omnipotent control (narcissistic grandiosity) and any concomitant antagonistic and abusive interpersonal patterns towards others. Similarly, when working with women with elevated narcissistic features there may be a need to attend to current themes of being ‘uncared for/unappreciated’ in their everyday life (and even directly with the therapist). This similarly needs to be explored, including any resulting emotional reactions (e.g., shame, envy, entitlement rage), how this relates to a metanarrative of personal victimhood (narcissistic vulnerability) which may then be used to justify antagonistic and abusive interpersonal patterns towards others.

Outlining such internal working models, emotional reactions and subsequent dysfunctional interpersonal patterns are central to effective treatment of personality disorder, including narcissistic personality disorder (Diamond et al., 2021 ), which then serves as the basis for intervention efforts. As such, given these identified links between gender, narcissistic functioning and intimate partner violence, our findings underscore the importance of assessing and managing risks of interpersonal violence and abuse when working with men and women with prominent narcissistic features as a standard component of clinical care.

In sum, the current findings contribute to the scarce literature on narcissism in women and highlights important gendered roots of the personality construct and gender-specific routes to IPV. Specifically, we found that maternal care negatively predicted vulnerable narcissism in women and grandiose narcissism in men, with paternal overprotectiveness also positively predicting grandiose narcissism in men, but not in women. Grandiose narcissism was a significant predictor of psychological IPV in men, whereas vulnerable narcissism significantly predicted physical/sexual and psychological IPV in women. A novel finding emerged where mother care was associated with reduced psychological IPV via lower vulnerable narcissism levels in women only. The implications of this study raise questions about the vast literature which predominantly portrays men as narcissistic and excludes women. Future research on narcissism should employ gender-inclusive assessments of narcissism that captures vulnerable features to enhance our theoretical understanding of this phenomenon in women. Interventions that target IPV in narcissistic perpetrators can be guided by the gendered risk markers outlined in the current study.

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Antisocial Personality Disorder

Complications

Living with aspd.

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Antisocial personality disorder (ASPD) is a mental health condition that affects how a person thinks, behaves, perceives things, and relates with others. The condition causes prolonged patterns of exploitation, manipulation, insensitivity, and violation of other people’s rights. Similar to other personality disorders, ASPD is pervasive. However, the severity of symptoms can range from mild lack of consideration for others to committing serious crimes.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) groups personality disorders into four categories: cluster A, cluster B, cluster C, and other personality disorders. ASPD belongs to cluster B personality disorders , which are characterized by constantly changing dramatic and emotional behaviors or thoughts.

An estimated 0.6% to 3.6% of adults live with ASPD, and it appears to be more common in people assigned male at birth than those assigned female at birth. While this condition can be challenging, the right support and treatment can help manage symptoms over time.

Antisocial Personality Disorder Symptoms

Antisocial personality disorder causes several pervasive symptoms that can start in childhood or early adolescence and last throughout life. The most common symptoms include:

• Inability to show care or concern when others are in distress
• Lack of remorse or regret for one’s actions
• Repeated breaking of the law
• Irresponsible and reckless behaviors that conflict with social norms
• Disregard for the safety of oneself or others
• Substance use
• Ability to act witty and charming but still exploit others
• Constantly engaging in fighting, lying, and stealing behaviors
• Tendency to flatter others and manipulate their emotions

These behaviors affect various spheres of life, often causing profound impairments in a person’s interpersonal relationships, career, daily functioning, and overall quality of life. 

The exact reason why some people develop antisocial personality disorder is not yet known. However, researchers and health experts do know that a combination of the following risk factors may play a role:

• Genetics: Some research estimates that 20% of people with ASPD have an immediate relative who also lives with the condition.
• Upbringing: Having a history of trauma, abuse , neglect, and poor parenting can increase the risk of ASPD.
• Medical conditions: Traumatic brain injuries , endocrine disorders, and brain tumors are all associated with a higher risk of this personality disorder.
• History of mental health conditions: Conduct disorder (a condition that causes aggressive and antisocial behaviors) occurs in children and teenagers, which can sometimes develop into ASPD as a person gets older.

If you or a loved one are experiencing symptoms or traits of antisocial personality disorder, getting a diagnosis can help manage symptoms and improve quality of life. That said, many people with personality disorders don't opt to receive medical or psychiatric care for their condition—so it's normal to see some hesitancy to visit a provider if your loved one may have a personality disorder.

However, if your loved one (or you yourself) are willing to seek care, meeting with a primary care provider or mental health specialist is a good start. It's worth noting that providers only diagnose antisocial personality disorder in adulthood (people who are 18 years old or older). However, many people exhibit some of the signs earlier in life and may have been diagnosed with conduct disorder in their adolescence or childhood.  

During the diagnostic process, your provider will perform a psychological evaluation to learn more about your symptoms, traits, moods, and behaviors. In some cases, your provider may also interview your loved ones to inquire about your personality. Your provider can only give you a diagnosis if you are 18 years old (or older) and show three or more of the following symptoms:

• Deceitfulness, such as lying and tricking others
• Repeatedly breaking the law
• Impulsivity or failure to make plans
• Aggression and irritability
• Constant irresponsible actions
• Reckless regard for personal and others' safety
• Indifference and lack of remorse

Antisocial Personality Disorder Treatment

Receiving a diagnosis for a personality disorder can feel overwhelming—and it's fine to feel however you feel. ASPD can sometimes be challenging to treat. That's because the condition often co-occurs with (or, happens at the same time as) other mental health conditions like anxiety or bipolar disorder . Some people with the condition also believe that there is nothing wrong with them or their behaviors and tend not to seek medical treatment on their own.

However, treatment can help significantly reduce symptoms. Everyone's treatment plan looks slightly different, but your healthcare team will likely suggest therapy, medications, or a combination.

Psychotherapy

Also called talk therapy, psychotherapy involves various techniques that mental health providers use to restructure harmful thoughts, behaviors, and emotions. The most common therapy options for people with antisocial personality disorder are:

• Cognitive behavioral therapy (CBT): A form of psychotherapy (talk therapy) that focuses on identifying and shifting unhelpful thought patterns and behaviors
• Social skills training (SST): A form of behavioral therapy that focuses on improving social skills
• Mentalization-based therapy (MBT): A form of psychotherapy that focuses on the connections between your mental state and behaviors and the mental states of others

Sometimes, healthcare providers also recommend group therapy (doing therapy sessions with other people with ASPD) or family therapy (adding loved ones to your therapy sessions) to help people with ASPD feel more support during their treatment journey.

Medications

Currently, no medication has been approved for specifically treating personality disorders. However, some health experts may recommend medications that help offset specific symptoms of ASPD, such as irritability, anger, depression, and anxiety .

If your healthcare provider thinks that medication may be an appropriate option for you, you may receive one of the following medication options:

• Antipsychotic medications, such as Risperdal (risperidone)
• Mood stabilizers, such as Tegretol (carbamazepine)
• Antidepressants , such as Desyrel (tradozone)

There is no way to prevent any personality disorder. However, researchers are actively studying whether prevention strategies exist to lower or eliminate the risk of developing a personality disorder.

One evidence-based study indicates that treatment or early intervention directed at children with antisocial behaviors and character traits may improve academic performance and prevent the development of antisocial personality in adolescence.

Another study suggests that treating impulsivity in early adolescence may help prevent the development of antisocial personality disorder later in life.

Antisocial personality disorder can be a difficult condition to live with and manage—especially because it raises the risk of other complications. If ASPD is left untreated, the condition can also increase the risk of:

• Substance use disorders
• Physical traumas or accidents due to reckless behaviors
• Sexually transmitted infections (STIs)
• Hepatitis C infection resulting from intravenous substance use
• Suicidal thoughts or attempts

Looking for Support?

If you are experiencing a crisis, or know someone who is, call or text the National Suicide Prevention Lifeline at 988 for free and confidential support 24/7. You can also visit SpeakingOfSuicide.com/resources for a list of additional resources or call the number below to reach the Substance Abuse and Mental Health Services Administration (SAMHSA) hotline.

Living with antisocial personality disorder can be incredibly challenging, both for the people diagnosed and their loved ones. However, evidence suggests that up to 31% of people with ASPD experience a significant improvement in symptoms with treatment. It may also be encouraging to know that ASPD generally improves as you get older.

If you have received a diagnosis of ASPD, your healthcare provider will work with you to give you the best treatment tailored to your specific needs. Additionally, they may also recommend some management strategies that can help you live with your condition in a more effective way. For example:

• Acknowledge that you need care and support
• Work with your healthcare team, family, and loved ones to improve your mental health
• Ensure that you follow your treatment plan as directed by your healthcare provider
• Practice self-care
• Limit alcohol and drug use
• Be patient with your treatment plan and not being too hard on yourself during your journey

Additionally, working with a healthcare provider you are comfortable with matters—and you deserve to receive treatment in a safe and supportive environment. That said, if you don't feel supported by your provider, it's absolutely OK to shop around for a provider that may benefit you and your overall needs.

Frequently Asked Questions

ASPD and borderline personality disorder (BPD) are both cluster B personality disorders. People with ASPD are more aggressive and physically violent, while people with BPD tend to struggle with much greater inward conflict, such as identity issues, fear of abandonment, and frequent mood swings.

BPD is more commonly diagnosed in people assigned female at birth, while ASPD is more prevalent in people assigned male at birth.

Sociopathy is an alternative name used for ASPD. However, the DSM-5 refers to this condition as antisocial personality disorder.

Symptoms for some people with certain personality disorders, such as ASPD, may improve as they get older. However, proper treatment by a qualified healthcare provider more significantly improves outcomes in the long run.

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