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Narcissistic Personality Disorder: A Clinical Perspective
Abstract
Narcissistic traits and narcissistic personality disorder (NPD) present specific diagnostic challenges. While they are often readily and straightforwardly identified, their presentation in some patients and the reasons for which such patients seek treatment may conceal significant narcissistic pathology. Recently, several empirical studies have confirmed that the phenotypic range of people with NPD includes individuals with insecure, shy, and hypersensitive traits with prominent internalized narcissistic features and functioning. Other studies have confirmed that internal emotional distress, interpersonal vulnerability, fear, pain, anxiety, a sense of inadequacy, and depressivity can also co-occur with narcissistic personality functioning. This paper focuses on integrating these findings into the diagnostic evaluation and initial negotiation of treatment for NPD. In patients with narcissistic traits or NPD, it is important to give attention to the two sides of character functioning, which include both self-serving and self-enhancing manifestations as well as hypersensitivity, fluctuations in self-esteem, and internal pain and fragility. This article highlights some of these seemingly incompatible clinical presentations of narcissistic traits and NPD, especially as they co-occur with depressivity and perfectionism, and it discusses implications for building a treatment alliance with a patient with such a predominant disorder of character functioning. The article also discusses the importance of retaining the NPD diagnosis as a separate type of personality disorder, with this range of features, in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DMS-5).
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“In narcissistic personality disorder, there is frequently a hypersensitivity to the evaluations of others and a fluctuation in the self-esteem between grandiose and depleted states, depending on life circumstances [16, 17]; these are personality features associated with an increased risk of both suicidal and non-suicidal self-injury [18, 19].”
From Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges (2020) · cites this paper as [17]
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Narcissistic Personality Disorder: Diagnostic and clinical challenges
Caligor, E., Levy, K. N., & Yeomans, F. E. (2015) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2014.14060723 · Cited by 271
“Regardless of severity, the grandiosity and defensiveness that characterize narcissistic personality disorder militate against acknowledging problems and vulnerabilities andmake engagement in any form of psychotherapy difficult (33).”
BackgroundAn Integrative Approach to the Assessment of Narcissism
Roche, M. J., Pincus, A. L., Lukowitsky, M. R., Ménard, K. S., & Conroy, D. E. (2013) · Journal of Personality Assessment · doi:10.1080/00223891.2013.770400 · Cited by 133
“…related to narcissistic vulnerability, a central aspect of pathological narcissism in contemporary clinical theory and research (Cain et al., 2008; Levy et al., 2009; Miller, Widiger, & Campbell, 2010; Pincus, 2013; Pincus & Lukowitsky, 2010; Pincus & Roche, 2011; Ronningstam, 2009, 2011a, 2011b).”
BackgroundConceptions of Narcissism and the DSM-5 Pathological Personality Traits
Wright, A. G. C., Pincus, A. L., Thomas, K. M., Hopwood, C. J., Markon, K. E., & Krueger, R. F. (2013) · Assessment · doi:10.1177/1073191113486692 · Cited by 129
Fluctuations in grandiose and vulnerable narcissistic states: A momentary perspective.
Edershile, E. A., & Wright, A. G. C. (2021) · Journal of Personality and Social Psychology · doi:10.1037/pspp0000370 · Cited by 112
“34 4.0 Discussion Clinicians have noted that narcissistic individuals fluctuate in their expressions of grandiosity and vulnerability (e.g., Kernberg, 1975; Wright, 2014; Pincus et al., 2014; Ronningstam, 2009, 2011).”
InfluentialPathological narcissism and interpersonal behavior in daily life.
Roche, M. J., Pincus, A. L., Conroy, D. E., Hyde, A. L., & Ram, N. (2012) · Personality Disorders Theory Research and Treatment · doi:10.1037/a0030798 · Cited by 109
“The PNI assesses the central aspects of narcissism identified in contemporary clinical theory and research (Pincus, in press) and is designed to be consistent with how narcissism presents in clinical practice (Kealy & Rasmussen, 2012; Ronningstam, 2011).”
BackgroundPerfectionism and narcissism: A meta-analytic review
Smith, M. M., Sherry, S., Chen, S., Saklofske, D. H., Flett, G. L., & Hewitt, P. L. (2016) · Journal of Research in Personality · doi:10.1016/j.jrp.2016.07.012 · Cited by 112
“Indeed, as noted by Ronningstam (2011), narcissists often ‘readily announce their perfectionistic strivings and ideals, often in combination with their contempt for the perceived imperfections of other people’ (p. 93).”
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“Based on previously described associations between the components of narcissistic and self-critical perfectionism in the theoretical (Ronningstam, 2011) and the empirical literatures (Hewitt & Flett, 1991), we also hypothesized that these higher-order constructs would be moderately to strongly correlated, but would be…”
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“, 2009), a self-report measure designed to assess the central aspects of narcissism identified in contemporary clinical theory and research, and to be consistent with how narcissism presents in clinical practice (Ronningstam, 2011; Wright, Lukowitsky, Pincus, & Conroy, 2010).”
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Edershile, E. A., & Wright, A. G. C. (2019) · Self and Identity · doi:10.1080/15298868.2019.1627241 · Cited by 65
“Clinical theory suggests that individuals fluctuate in their levels of grandiosity and vulnerability (Kernberg, 1975; Pincus et al., 2014; Pincus & Lukowitsky, 2010; Ronningstam, 2009, 2011; Wright, 2014).”
Modernity and narcissistic personality disorder.
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“NPD patients are more likely to be divorced and/or become unemployed, often leading to depressive symptoms (Ronningstam, 2011).”
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Green, A., MacLean, R., & Charles, K. E. (2021) · Psychological Reports · doi:10.1177/00332941211027322 · Cited by 60
“First, to modify the current NPD criteria with explicit content covering vulnerable narcissistic features (Fossati et al., 2005; Miller et al., 2010; Pincus & Lukowitsky, 2010; Ronningstam, 2011), thereby indirectly addressing the gender issue.”
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“One could argue against this critique given that (a) the PNI was not created to assess the narrowly defined DSMIV/DSM-5 NPD with its limited utility (Ronningstam, 2011) and (b) the PNI-Exploitativeness scale matches the expected profiles (r = .66).”
BackgroundResultDepressive tendencies and pathological narcissism among psychiatric outpatients
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“…and vulnerability subscales being highly correlated in the present sample, r = 0.69, p<0.001, and in accordance with conceptual accounts of typically intertwined grandiosity and vulnerability (Caligor et al., 2015; Kealy and Rasmussen, 2012; Ronningstam, 2011), the total pathological 157”
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“These phenotypes share an underlying exaggerated sense of self-importance and entitlement (Dickinson & Pincus, 2003; Russ, Shedler, Bradley, & Westen, 2008) as well as impaired self-esteem regulation (Ronningstam, 2011).”
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“Current theoretical conceptualizations of pathological narcissism view shame as a major component of narcissistic vulnerability (Horowitz, 2009; Kernberg, 2009; Ronningstam, 2011), such that these persons are prone to avoiding or reducing explicit feelings of shame by using different intra- and interpersonal strategie…”
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Hascalovitz, A., & Obhi, S. S. (2015) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2015.00013 · Cited by 29
“This process has been associated with threatening swings in self-esteem, which further contribute to the fragility of the narcissistic mindset (Ronningstam, 2011a; for more on manifestation of clinical narcissism see Dimaggio et al., 2006, 2008).”
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“Narcissistic perfectionism is often discussed in theory (e.g., Ellis 1997; Ronningstam 2011), but empirical tests remain scarce.”
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Erkoreka, L., & Navarro, B. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2017.07.061 · Cited by 29
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“Although this often involves maladaptive efforts at self-enhancement—such as inflated views of the self and devalued views of others—the key issue is a deficiency in healthy self-regulation (Ronningstam, 2011).”
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“In this way, individuals with pathological narcissism struggle with healthy self-regulation and positive selfregard [67], as the inflated and grandiose self is fragile,”
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“Moreover, individuals high in pathological narcissism often experience both grandiosity and vulnerability (Caligor et al., 2015; Ronningstam, 2011).”
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BackgroundPsychopathology and personality functioning
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Case Conceptualization in Clarification-Oriented Psychotherapy
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“Furthermore, literature also indicates that perfectionism is a central feature of narcissism (Ronningstam, 2010, 2011), and is a strong predictor of depression (Hewitt, Flett, & Ediger, 1996).”
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Paris, J. (2020)
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Antisocial Personality Disorder
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Modernity and Personality Disorder
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A Biopsychosocial Model of Personality Disorders
Paris, J. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108867542.012
Social Context and Personality
Paris, J. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108867542.006
Paris, J. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108867542.008
Paris, J. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108867542.011
Personality Traits and Personality Disorders
Paris, J. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108867542.005
Narzisstische Persönlichkeitsstörungen
Sachse, R. (2020) · Springer eBooks · doi:10.1007/978-3-662-45995-9_42-1
Paris, J. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108867542.014
Zeigler‐Hill, V., & Jordan, C. (2013) · Oxford University Press eBooks · doi:10.1093/obo/9780199828340-0113 · Cited by 2
Motivations Underlying Mass Acts of Violence
Barone, P. A. (2022) · IGI Global eBooks · doi:10.4018/978-1-6684-7464-8.ch001
Séguin, D., & Descôteaux, J. (2023) · SSRN Electronic Journal · doi:10.2139/ssrn.4496504
Metadata
- Authors
- Ronningstam, E.
- Affiliations
- Harvard University (US)
- Corresponding author
- Ronningstam, Elsa
- ORCID
- Ronningstam, Elsa
- Venue
- Journal of Psychiatric Practice
- Published
- 2011-03
- Volume
- 17
- Issue
- 2
- Pages
- 89-99
- ISSN
- 1527-4160 (ISSN-L)
- 1538-1145
- OpenAlex
- W2015531628
- Cited by
- 111
- References
- 0
- Citations by year
- 2026: 2 · 2025: 7 · 2024: 11 · 2023: 7 · 2022: 4 · 2021: 5 · 2020: 25 · 2019: 8 · 2018: 3 · 2017: 5 · 2016: 4 · 2015: 9 · 2014: 7 · 2013: 5 · 2012: 5
- FWCI
- 7.24
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Psychiatric Practice (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Personality Traits and Psychology
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- narcissistic personality disorder, narcissistic personality traits, diagnostic assessment, treatment alliance, perfectionism, hypersensitivity, DSM-5, personality disorder diagnosis
- MeSH terms
- Adult, Depression, Female, Humans, Male, Middle Aged, Narcissism, Personality Disorders, Self Concept, Comorbidity, Diagnostic and Statistical Manual of Mental Disorders
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