Reflections on Narcissism (part 1): Competing Ways to Conceptualize Narcissistic Personality Disorder
Narcissism—be it the concept or its referent—is clearly having a moment in the wider culture. The demoniacal figure of The Narcissist is all over social media. In the 2010s, a yearly average of 357 peer-reviewed articles had the word “narcissism” in their abstracts, up from 173 in the year 2000 (see Weiss and Campell in Cambridge Handbook of Personality Disorders, 2020). Of course, it’s hard to know how to interpret such numbers, and the concept of narcissism arguably went through a previous vogue in the 1970s, thanks to Kohut, Kernberg, and Christopher Lasch—maybe this will be the topic of a future post.
As Jonathan Shedler and David Puder discuss in this podcast,
the popular portrayal of narcissism is frequently one-dimensional. In the psychodynamic
tradition, however, among other clinical approaches, one
finds distinctions between (a) normal, developmentally-necessary narcissism and
(b) pathological narcissism, as well as between different types of pathological
narcissism. These distinctions, in my opinion, open up room for more nuanced conceptualizations
of narcissism.
In this series of posts, I want to explore attempts at
conceptualizing pathological narcissism. However, since the term “pathological
narcissism” has become a construct in its own right and in competition with
some of the other approaches in psychopathology, I suppose I should use the
more ungainly expression “attempts at conceptualizing narcissism in its pathological
or disordered forms.” As usual on this blog, my focus will be on conceptual
questions, rather than empirical ones, although I will have to say a bit about
these too.
There’s so much potentially to talk about here that I
scarcely know where to start, so I’ll start with the most orthodox way of
thinking about narcissism in its disordered forms, the construct of
Narcissistic Personality Disorder (NPD). Dawood et al (2020) have an excellent
review article in the Cambridge Handbook of Personality Disorders (pp. 277–291).
They suggest that there are three basic approaches at present to
conceptualizing NPD.
I. The categorical approach to NPD: DSM-5, section II
This is the most orthodox approach to NPD. It is probably
the only one that nonspecialist master’s-level clinicians know, and it is found
in the personality disorders section of DSM-5. There, we find it classed among
the “Cluster B” personality disorders, such as Borderline Personality Disorder (BPD)
or Antisocial Personality Disorder. It is defined thus: “A pervasive pattern of
grandiosity (in fantasy or behavior), need for admiration, and lack of empathy,
beginning by early adulthood and present in a variety of contexts” (669). In
the polythetic criteria approach of the DSM, an individual needs to meet 5 out of
9 of the following criteria for a diagnosis (I am paraphrasing and somewhat
simplifying here): 1) grandiose sense of self-importance; 2) fantasies of
power, beauty, success, brilliance, or love; 3) belief in special status; 4) need
for excessive admiration; 5) sense of entitlement; 6) exploitative of others;
7) lacking in empathy; 8) envious; 9) arrogant attitudes (DSM-5 pp. 669-670).
Dawood et al note that the core of the DSM-5 categorical NPD
construct is pathological grandiosity. (Of course, what exactly “pathological”
means in psychopathology is a complex question—see my earlier posts on this topic.) This is not just thinking you’re better than others sometimes or
that only special people can understand you in some contexts or situations. But
the problem Dawood et al observe here is that DSM-5 has stripped away one of
the core insights of the clinical tradition of conceptualizing pathological
narcissism, namely that grandiosity is often accompanied by vulnerability:
to shame, to humiliation, to emotion dysregulation, and so on. Dawood et al argue
that the vulnerability component of NPD was removed after DSM-III in order to
decrease overlap with other personality disorders (e.g., BPD) and to improve
interrater reliability (i.e., the likelihood that people using the same set of
diagnostic constructs will diagnose the same patients the same way).
The authors go on to note that the vulnerability component
of the NPD construct nevertheless makes its way back in later in the section on
NPD. For those unfamiliar with the DSM, each diagnostic construct usually
begins with a statement with a sentence stating the “essential features” of the
clinical entity, followed by a numbered checklist of diagnostic criteria. After
the criteria, however, we typically get a more discursive treatment of the
disorder. In the “Associated Features” section of DSM-5, we find the following:
“Vulnerability in self-esteem makes individuals with
narcissistic personality disorder very sensitive to ‘injury’ from criticism or
defeat. Although they may not show it outwardly, criticism may haunt these
individuals and may leave them feeling humiliated, degraded, hollow, and empty.
They may react with disdain, rage, or defiant counterattack. Such experiences
often lead to social withdrawal or an appearance of humility that may mask and
protect the grandiosity.” (p. 672)
These statements are much more in line with the clinical
tradition, where the emphasis tends to be less strictly on grandiosity and more
on the tendency to move between grandiosity and shame. However, by the
categorical DSM-5 NPD criteria alone, it would not be a straightforward process
to diagnose someone with a more vulnerable presentation with NPD.
II. The hybrid categorical–dimensional approach to NPD:
DSM-5, section III (the AMPD)
DSM-5, however, also includes a second model of personality
disorders in section III (“Emerging Measures and Models”) of the manual, the
Alternative Model (AMPD). The AMPD is a hybrid model, incorporating both
dimensional and categorical aspects. In earlier posts, I discuss this
distinction and also review a similar approach, the one found in ICD-11. A
personality disorder in the AMPD scheme involves a dimensional rating of
impairment in self and interpersonal functioning, rated from 0 to 4 in terms of
severity, with moderate impairment (i.e., a score of 2) being the cutoff for
diagnosis, and one or pathological traits, chosen from a list of 25 traits
organized into five pathological personality trait domains (Negative
Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism) that
roughly map onto the Five Factor Model of normal personality. Impairments in
self and interpersonal functioning involve impairments in sense of identity,
self-direction, empathy, and intimacy. The AMPD also requires that the traits
and impaired functioning be consistent and pervasive across many areas of life
and present from adolescence or early adulthood.
As it turns out, the AMPD also decided to retain some, but
not all, of the categorical personality disorder diagnoses from section II. The
translation, however, from one system to another involves a transformation.
Before looking at the AMPD definition of NPD, however, I would like to consider
how elements of NPD could be delineated just by using criteria A (functional impairment)
and B (pathological traits).
Let us start with traits. The trait grandiosity appears
under the Antagonism domain, hostility appears under Negative Affectivity, and
several other features perhaps more linked with vulnerable narcissism appear
under Detachment, such as intimacy avoidance or depressivity (see pp. 779-780).
(I will say that I find criterion A a bit confusing here,
since it is not entirely clear to me whether one should be looking for moderate
impairment in all four of these domains or just in one of them. However, the categorical
diagnostic constructs suggest that a minimum requirement is moderate impairment
in two out of four.)
The AMPD construct of NPD can be found on pp. 767-768. Here
we no longer find talk of essential features, but rather of “typical” or “characteristic”
ones, as well as an associated trait domain—in this case, Antagonism. Here is
the typical features statement: “Typical features of narcissistic personality
disorder are variable and vulnerable self-esteem, with attempts at regulation
through attention and approval seeking, and either overt or covert grandiosity.
Characteristic difficulties are apparent in identity, self-direction, empathy,
and/or intimacy.”
Look at just how much the accent has shifted here! Section
II prioritizes grandiosity; in section III, the diagnostician is looking,
rather, at “variable and vulnerable self-esteem.” Grandiosity occurs at the
very end of the first sentence and exists in the service of self-esteem
regulation. Moreover, we get a nod to the long clinical tradition of
distinguish overt and covert pathological narcissism. The difference here is
not just, however, that variable and vulnerable self-esteem has edged out
grandiosity. Instead, AMPD shifts gears entirely from DSM-5’s typical
atheoretical descriptive approach into an account of the putative
psychodynamics underlying grandiosity. Put differently, the AMPD attempts to
explain why people with NPD are grandiose, rather than merely observing that
they are.
After this initial statement of typical and characteristic
features, we get a requirement of at least moderate impairment in two of the
four personality domains. Dawood et al, in contrasting sections II and III of
DSM-5, stress criterion A1 in particular, which concerns impairments in
identity functioning: “Excessive reference to others for self-definition and
self-esteem regulation; exaggerated self-appraisal inflated or deflated, or
vacillating between extremes; emotional regulation mirrors fluctuations in
self-esteem.” They underline that, in this approach, both excessive
self-idealization and excessive self-devaluation, as well as oscillation
between these extremes, can be treated as indicative of NPD. Dawood et al
rightly note that this is a far cry from the unipolar focus on grandiose
self-esteem in section II.
After criterion A, we get criterion B, or the requirement that
both the traits of grandiosity and attention-seeking from the Antagonism domain
be present. Other traits, including some of the ones I mentioned above from
Negative Affectivity, can be added as further specifiers. Dawood et al propose
a more open-ended approach, in which traits from Negative Affectivity might
also be included directly in criterion B (Dawood et al, 2020, p. 281). (I think
what they mean is that instead of requiring both grandiosity and
attention-seeking for diagnosis, we might require grandiosity plus one more of
three or four traits, including depressivity, emotional lability, etc.)
III. Pure dimension: The construct of pathological
narcissism
The third and final conceptualization Dawood et al consider
is a purely dimensional approach rooted in the clinical tradition of the
construct of pathological narcissism. This is a dual model of both grandiosity
and vulnerability. It eschews strict categorization altogether. The virtue of
this approach is that it can make better sense of the role of anger, envy,
aggression, helplessness, emptiness, low self-esteem, shame, avoidance of
interpersonal relationships, and suicidality in narcissism that has assumed a
disordered form.
I think the basic notion of pathological narcissism should
be clear enough at this point for me to pause. It makes sense to devote a
separate post to this construct, as it is far less codified than the two DSM-5
definitions of NPD.
I will note that the Cambridge Handbook includes
commentaries on its chapters, as well as authors’ responses, and things get a
bit heated here. Brandon Weiss and W. Keith Campbell argue that NPD is a wide
and heterogeneous construct and that we are lacking in empirical support for
the idea of a single underlying phenomenon connecting narcissism in its
grandiose manifestations from narcissism in its vulnerable tones. They hold
that, despite clinical wisdom, there is little evidence that individuals
actually “oscillate” between grandiosity and vulnerability (p. 293). Dawood et al then
rejoin by implying that Weiss and Campbell are lacking in clinical experience
and that ivory tower approaches to personality disorder that attempt to reduce
it to trait personality psychology are clinically useless. This is all very
interesting and points to some of the deeper fractures in the field of
personality disorders that I have talked about before. Elsa Ronningstam and Tiffany
Russell, for their part, elaborate on the role of trauma in narcissism and the connection
between narcissism and other pathological personality traits or forms of psychopathology.
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