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Personality Disorders: Theory, Research, and Treatment © 2014 American Psychological Association 2014, Vol. 4, No. 4, 000 1949-2715/14/$12.00 DOI: 10.1037/per0000031 Narcissistic Grandiosity and Narcissistic Vulnerability in Psychotherapy Aaron L. Pincus Nicole M. Cain Pennsylvania State University Long Island University–Brooklyn Aidan G. C. Wright University of Pittsburgh This article briefly summarizes the empirical and clinical literature underlying a contemporary clinical model of pathological narcissism. Unlike the DSM Narcissistic Personality Disorder (NPD), this clinical model identifies and differentiates between two phenotypic themes of dysfunction—narcissistic grandi- osity and narcissistic vulnerability—that can be expressed both overtly and covertly in patients’ ways of thinking, feeling, behaving, and participating in treatment. Clinical recognition that narcissistic patients can and often do present for psychotherapy in vulnerable states of depression, anxiety, shame, and even suicidality increases the likelihood of accurate diagnosis and effective treatment planning. This article provides case examples derived from psychotherapies with narcissistic patients to demonstrate how narcissistic grandiosity and narcissistic vulnerability concurrently present in patients who seek treatment. Keywords: narcissism, grandiosity, vulnerability, psychotherapy As a result of the multiplicity of meanings associated with Ansell, & Pincus, 2013). Thus, a clinician relying solely on DSM narcissism across psychology and psychiatry, there is no gold NPD diagnostic criteria may fail to recognize pathological narcis- standard with which to synthesize clinical observations and find- sism in a presenting patient. ings. Relying solely on the criteria for Narcissistic Personality Three suggestions for revising the DSM diagnosis of NPD have Disorder (NPD) found in the Diagnostic and Statistical Manual of appeared in the literature. One suggestion is to revise the DSM Mental Disorders-5 (DSM-5; APA, 2013) for diagnosis and treat- criteria to include features reflecting narcissistic vulnerability (e.g., ment planning is unsatisfactory for many reasons. These include Ronningstam, 2011). An alternative proposal would consider nar- NPD exhibiting the lowest prevalence rate of any of the DSM cissistic vulnerability a specifier for NPD diagnoses (e.g., NPD personality disorders, which is inconsistent with the frequency of with vulnerable features) similar to specifiers used for other diag- narcissistic diagnosis found in clinical practice (Cain, Pincus, & noses (Miller, Gentile, Wilson, & Campbell, 2013). A third alter- Ansell, 2008), the DSM criteria’s narrow emphasis on grandiosity native considers pathological narcissism a facet of general person- and its limited fidelity to actual clinical phenomenology (Pincus, ality pathology representing a core feature of all PDs rather than a 2011), and a lack of clinical utility and treatments for NPD specific PD diagnosis (Morey & Stagner, 2012). Research is (Dhawan, Kunik, Oldham, & Coverdale, 2010). required to resolve this nosological debate; and, all of these pro- Moving beyond NPD, reviews of the clinical, psychiatric, and posals require that diagnosticians and psychotherapists recognize social/personality psychology literature clearly paint a broader the clinical presentation of pathological narcissism in their pa- portrait of pathological narcissism encompassing two phenotypic tients. themes of dysfunction, narcissistic grandiosity and narcissistic This article focuses on describing the clinical presentation of vulnerability (Cain et al., 2008; Pincus & Roche, 2011). The lack pathological narcissism. First, we briefly summarize the literature of sufficient vulnerable DSM NPD criteria is now a common supporting the broader conceptualization of pathological narcis- This document is copyrighted by the American Psychological Association or one of its alliedcriticism publishers. (Miller, Widiger, & Campbell, 2010; Ronningstam, sism, and then we present case examples drawn from psychother- This article is intended solely for the personal use of2009). the individual user and is not to be disseminated broadly. The overly narrow construct definition of pathological apies with narcissistic patients in a community mental health narcissism found in DSM NPD limits its clinical validity and outpatient clinic to demonstrate how narcissistic grandiosity and utility, as narcissistic patients are more likely to seek treatment narcissistic vulnerability concurrently present in patients seeking when they are in a vulnerable self-state (Ellison, Levy, Cain, treatment. Narcissistic Grandiosity and Narcissistic Vulnerability To the layperson, narcissism is most often associated with Aaron L. Pincus, Department of Psychology, Pennsylvania State Uni- arrogant, conceited, and domineering attitudes and behaviors, versity; Nicole M. Cain, Department of Psychology, Long Island Univer- sity— Brooklyn; Aidan G. C. Wright, Department of Psychology, Univer- which are captured by the term narcissistic grandiosity. This sity of Pittsburgh. accurately identifies some common expressions of maladaptive Correspondence concerning this article should be addressed to Aaron L. self-enhancement, disagreeableness, and lack of empathy associ- Pincus, Department of Psychology, 358 Moore Building, Pennsylvania ated with pathological narcissism. However, an emerging contem- State University, University Park, PA 16803. E-mail: [email protected] porary clinical model of pathological narcissism (Pincus & Lu- 1 2 PINCUS, CAIN, AND WRIGHT kowitsky, 2010; Roche, Pincus, Lukowitsky, Ménard, & Conroy, Conroy, 2010). Narcissistic grandiosity involves intensely felt 2013) combines grandiosity with clinically important regulatory needs for recognition and admiration giving rise to urgent motives impairments that lead to self, emotional, and behavioral dysregu- to seek out self-enhancement experiences. When this dominates lation in response to ego threats or self-enhancement failures (see the personality, the individual is concomitantly vulnerable to in- Figure 1). creased sensitivity to ego threat and subsequent self, emotion, and Needs for admiration and motives to self-enhance are normal behavioral dysregulation (i.e., narcissistic vulnerability). aspects of personality, but they become pathological when they are extreme and coupled with impaired regulatory capacities (Pincus, Overt and Covert Narcissism 2013). It is normal for individuals to strive to see themselves in a positive light and to seek experiences of self-enhancement, such as The terms overt and covert narcissism are frequently used in successful achievements and competitive victories. Most individ- the psychological literature. Unfortunately, many incorrectly uals manage these needs effectively, seek out their gratification in associate overt expressions of narcissism exclusively with gran- culturally and socially acceptable ways and contexts, and regulate diosity and covert expressions of narcissism exclusively with self-esteem, negative emotions, and interpersonal behavior when vulnerability. There is no empirical support for these linkages. disappointments are experienced. In contrast, pathological narcis- DSM NPD criteria as well as items on various self-reports, sism involves impairment in the ability to regulate the self, emo- interviews, and rating instruments assessing pathological nar- tions, and behavior in seeking to satisfy needs for recognition and cissism include a mix of overt elements (behaviors, expressed admiration. Put another way, narcissistic individuals have notable attitudes, and emotions) and covert experiences (cognitions, difficulties transforming narcissistic needs (recognition and admi- private feelings, motives, needs). Our clinical experience with ration) and impulses (self-enhancement motivation) into mature narcissistic patients indicates they virtually always exhibit both and socially appropriate ambitions and conduct (Roche et al., covert and overt grandiosity and covert and overt vulnerability. 2013). As we depict in Figure 1, the distinction between overt and In this model, grandiose symptoms consistent with DSM NPD covert expressions of narcissism is secondary to phenotypic exist in tandem with impaired regulation, or narcissistic vulnera- variation in grandiosity and vulnerability. bility, reflected in experiences of anger, envy, aggression, help- lessness, emptiness, low self-esteem, shame, social avoidance, and Case Examples even suicidality. Evidence for the two phenotypic themes of nar- 1 cissistic grandiosity and narcissistic vulnerability comes from the- In the following cases, we first provide an example of a patient ory and research in clinical psychology, psychiatry, and social/ meeting DSM NPD criteria and then provide two examples of personality psychology (Cain et al., 2008; Pincus & Roche, 2011); patients we diagnose as suffering from pathological narcissism, but and in recent years, recognition of both grandiose and vulnerable may not meet DSM criteria because of their pronounced vulnera- themes of narcissistic dysfunction has increasingly become the bility. In portraying these latter cases, we opted to present their norm (e.g., Kealy & Rasmussen, 2012; Ronningstam, 2011; Russ, vulnerable characteristics first, followed by their grandiose fea- Shedler, Westen, & Bradley, 2008; Wright, Lukowitsky, Pincus, & tures. We chose this approach because narcissistic patients who seek outpatient treatment in community mental health centers typically