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Pathological Narcissism and Narcissistic Personality Disorder ANRV407-CP06-08 ARI 17 November 2009 21:25 V I E E W R S Review in Advance first posted online E on December 14, 2009. (Changes may I N C still occur before final publication N online and in print.) A D V A Pathological Narcissism and Narcissistic Personality Disorder Aaron L. Pincus and Mark R. Lukowitsky Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania 16802; email: [email protected], [email protected] Annu. Rev. Clin. Psychol. 2010. 6:8.1–8.26 Key Words The Annual Review of Clinical Psychology is online personality disorders, criterion problem, narcissistic grandiosity, at clinpsy.annualreviews.org narcissistic vulnerability, diagnosis This article’s doi: 10.1146/annurev.clinpsy.121208.131215 Abstract Copyright c 2010 by Annual Reviews. We review the literature on pathological narcissism and narcissistic per- All rights reserved sonality disorder (NPD) and describe a significant criterion problem re- 1548-5943/10/0427-0001$20.00 lated to four inconsistencies in phenotypic descriptions and taxonomic models across clinical theory, research, and practice; psychiatric diagno- sis; and social/personality psychology. This impedes scientific synthesis, weakens narcissism’s nomological net, and contributes to a discrepancy Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org between low prevalence rates of NPD and higher rates of practitioner- by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only. diagnosed pathological narcissism, along with an enormous clinical lit- erature on narcissistic disturbances. Criterion issues must be resolved, including clarification of the nature of normal and pathological narcis- sism, incorporation of the two broad phenotypic themes of narcissistic grandiosity and narcissistic vulnerability into revised diagnostic crite- ria and assessment instruments, elimination of references to overt and covert narcissism that reify these modes of expression as distinct narcis- sistic types, and determination of the appropriate structure for patho- logical narcissism. Implications for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the science of personality disorders are presented. 8.1 Changes may still occur before final publication online and in print. ANRV407-CP06-08 ARI 17 November 2009 21:25 2008), and despite narcissism’s longevity as a Contents construct in psychology and psychiatry, action must be taken to resolve disjunctions and in- INTRODUCTION .................. 8.2 tegrate findings in future conceptualizations of PHENOTYPIC AND pathological narcissism, otherwise continuing TAXONOMIC ISSUES ........... 8.2 disparate efforts will impede progress toward a Organizing the Tower of Babel: more sophisticated understanding of this com- Phenotypic and Taxonomic plex clinical construct. When this state of affairs Inconsistencies in is combined with potentially significant revi- Conceptualizations sions to the personality disorders in the upcom- of Narcissism ................... 8.3 ing DSM-V (Clark 2007, Krueger et al. 2008), ASSESSMENT.......................8.11 the current status of pathological narcissism and Narcissistic Personality Disorder . 8.12 NPD are truly in flux. Pathological Narcissism ............ 8.12 There have been a number of valuable and Narcissism and the Five-Factor comprehensive reviews of pathological narcis- Model of Personality ............ 8.14 sism and NPD in recent years (Cain et al. 2008; Limitations of Self-Reports, Levy et al. 2007, 2009; Ronningstam 2005a,b, Interviews, and Observer-Based 2009). Taken as a whole and with varying em- Measures ....................... 8.14 phases, these reviews document many of the is- Informant Ratings ................. 8.15 sues giving rise to the difficulties integrating RECOMMENDATIONS AND scientific and clinical knowledge on narcissistic FUTURE DIRECTIONS ......... 8.15 disturbances, and they provide excellent sum- CONCLUSION ..................... 8.17 maries of the contemporary clinical and empir- ical literature. In this article, we hope to avoid simply providing a redundant review and take a number of steps to achieve this aim. First, our INTRODUCTION Narcissism: ability to initial sections review and delineate problems regulate self-esteem The concept of narcissism can be traced to with construct definition and suggest potential and manage needs for the Greek myth of Narcissus and its retelling ways to clarify the construct of narcissism amid affirmation, validation, in Homeric hymns. Narcissism has a relatively the phenotypic and taxonomic diversity found and self-enhancement from the social long history as a psychological construct as in the literature. Second, when we turn to an ex- environment well, beginning with Havelock Ellis (1898) and amination of assessment, we consider the topic NPD: narcissistic early psychoanalytic theorists (e.g., Freud 1914) with regard to the major phenotypic and taxo- personality disorder through the development of object relations nomic issues we discuss next. DSM-V: Diagnostic and self psychological theories (Kernberg 1967, Annu. Rev. Clin. Psychol. 2010.6. Downloaded from arjournals.annualreviews.org and Statistical Manual Kohut 1968) and later ascribed to Axis II of PHENOTYPIC AND by University of Bergen UNIVERSITETSBIBLIOTEKT on 01/04/10. For personal use only. of Mental Disorders, the Diagnostic and Statistical Manual of Men- Fifth Edition tal Disorders, Third Edition (DSM-III; Am. Psy- TAXONOMIC ISSUES Criterion problem: chiatr. Assoc. 1980) as narcissistic personal- Reviews of the literature on pathological inconsistent construct ity disorder (NPD). Since the publication of narcissism and NPD converge in concluding definition leading to DSM-III Axis II, both clinical interest and that the clinical phenomenology described disparate operationalizations, psychological research on narcissism have in- across—and even within—disciplines is quite assessment creased. There is now a broad theoretical and diverse (Ronningstam 2005b, 2009) and that instruments, and empirical literature on narcissism that spans the narcissism is inconsistently defined and assessed research programs that related fields of clinical psychology, psychiatry, across clinical psychology, psychiatry, and so- hamper development and social/personality psychology. However, cial/personality psychology (Cain et al. 2008). of a cohesive this literature is poorly calibrated across the dis- This leads to a fundamental criterion problem V knowledgeI E base E W ciplines (Cain et al. 2008, Miller & Campbell (Austin & Villanova 1992, Wiggins 1973), R S 8.2 Pincus · Lukowitsky I N E C A N D V A Changes may still occur before final publication online and in print. ANRV407-CP06-08 ARI 17 November 2009 21:25 one that is particularly vexing for complex psychiatric diagnosis, and social/personality constructs such as narcissism and many other psychology raises fundamental questions about mental disorders (Acton 1998). Simply put, the appropriate descriptive characteristics there is no gold standard as to the meaning of and diagnostic criteria that best exemplify the construct and thus whether it is clinically narcissism. This is truly unfortunate because described or empirically measured, it can be we strongly believe pathological narcissism difficult to synthesize among and across clinical is an important clinical problem associated observations and empirical findings. In his with significant functional impairments (Miller general discussion of the criterion problem and et al. 2007, Stinson et al. 2008) and several related construct validity issues in clinical psy- related areas of maladjustment, including DSM chology, McGrath (2005) observed that “The Axis I disorders, psychopathy, interpersonal disparity between the diagnostic nomenclature problems and relational dysfunction, substance and actual psychiatric phenomena is largely use and abuse, aggression and sexual aggres- ignored, and extensive research is conducted sion, impulsivity, homicidal ideation, and to understand the psychosocial and treatment parasuicidal/suicidal behaviors (Pincus et al. implications of the existing diagnostic cate- 2009; Ronningstam 2005a,b). We identified gories” (p. 114). We can think of no better four interpenetrating aspects of descriptive summary of the state of affairs found in the phenomenology and taxonomy that are incon- current clinical and empirical literature on sistently addressed in the literature on patho- pathological narcissism and particularly NPD. logical narcissism and NPD, leading to a poorly This disparity is also evident when comparing coordinated theoretical and empirical base and the low prevalence rate (0.0% to 5.7%, median a patchy nomological net. These inconsisten- <1.0%) of DSM NPD diagnosis in most cies involve diversity in conceptualizations of epidemiological studies (Mattia & Zimmerman narcissism’s Nature (Normal, Pathological), 2001, Zimmerman et al. 2005) with the greater Phenotype (Grandiosity, Vulnerability), Ex- frequency of narcissistic diagnosis found in pression (Overt, Covert), and Structure (Cat- clinical practice (Doidge et al. 2002, Morey egory, Dimension, Prototype) (see Figure 1). & Ochoa 1989, Ronningstam & Gunderson 1990, Shedler & Westen 2007, Westen 1997, Pathological and normal narcissism. Nar- Westen & Arkowitz-Westen 1998). It is notable cissism can be conceptualized as one’s capac- that the most recent epidemiological study ity to maintain a relatively positive self-image of NPD (Stinson et al. 2008)
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