Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions

Treating Narcissistic Disorders in General Psychiatry: Practical Application of Transference-Focused Psychotherapy Principles

Patients with primary or co-occurring narcissistic disorders are seen routinely in general psychiatry settings. Contemporary trends in training and practice have impacted psychiatrists' skills and confidence in identifying and treating these disorders, which can range from relatively benign to high-acuity presentations. The goal of this article is to introduce key principles derived from transference-focused psychotherapy (TFP) for use by clinicians in general practice in their work with patients with narcissistic disorders, even when those clinicians do not routinely provide individual psychotherapy. Practical application of TFP principles in work with patients with narcissistic disorders in general psychiatry are proposed, including in diagnostic evaluation, family engagement, prescribing, and safety assessment and risk management calculus. Many psychiatrists whose practices are focused primarily on psychopharmacology, or a "medical model," may not appreciate fully the impact of pathological narcissism in their work. Clinicians who may benefit from familiarity with TFP principles in work with patients with narcissistic disorders include the approximately one-half of U.S. psychiatrists who do not offer psychotherapy in their practice.

Narcissistic personality disorder in the ICD-11: Severity and trait profiles of grandiosity and vulnerability

Modern diagnostic and classification frameworks such as the ICD-11 and DSM-5-AMPD have adopted a dimensional approach to diagnosing personality disorder using a dual "severity" and "trait" model. As narcissistic personality has historically struggled to be adequately captured in dominant diagnostic systems, this study investigated the utility of the new ICD-11 framework in capturing diverse narcissistic expressions. Participants were mental health clinicians (N = 180, 67% female, age = 38.9), who completed ratings of ICD-11 personality severity, trait domains and a clinical reflection for two hypothetical case vignettes reflecting either prototypical "grandiose" or "vulnerable" narcissism. The majority of clinicians (82%) endorsed a diagnosis of personality disorder for both grandiose and vulnerable vignettes. Discriminant elements of personality impairment included rigid, unrealistically positive self-view, low empathy and high conflict with others for grandiosity, and incoherent identity, low self-esteem and hypervigilant, avoidant relations with others for vulnerability. Regarding trait profile, grandiose narcissism was predominately dissocial whereas vulnerable narcissism was primarily associated with negative affectivity and detachment. Qualitative responses highlight distinct clinical themes for each presentation. These findings suggest that clinicians using the ICD-11 framework are able to identify common core elements of personality dysfunction in grandiose and vulnerable narcissism while also recognizing their distinctive differences.

Association between pathological narcissism and emotion regulation: The role of self-mentalizing?

Pathological narcissism (PN) is a common psychopathological issue leading to maladaptive strategies to cope with self-esteem threats, including self-enhancement and exploitation (grandiose strategies) or internalized shame, depression, and social withdrawal (vulnerable strategies). Mentalizing is a key process for regulating self and other representations and their associated emotions. Patients with PN further struggle with emotion dysregulation (ED), which during development is intertwined with the growing capacity to mentalize. We seek to contribute to emerging empirical data documenting the associations between PN and ED and between PN and mentalizing, and to provide information on the nature of their mutual relationships. In the present study, we assessed PN, ED, and three mentalizing dimensions (mentalizing self, other, and motivation to mentalize) in 183 patients consulting in our outpatient unit specialized in ED. We found that narcissistic vulnerability was negatively associated with self-mentalizing and positively associated with overall ED, both even after adjustment for borderline and attention deficit hyperactivity disorder (ADHD) symptoms. However, the association with ED was not maintained after further adjustment for self-mentalizing or overall-mentalizing, which suggests that mentalizing may play a mediating role in this relationship. On the other hand, narcissistic grandiosity was positively associated with other-mentalizing and ED and negatively associated with self-mentalizing in bivariate analyses, but these last two associations were not maintained after adjustment for comorbid borderline and/or ADHD symptomatology. This study provides new information on the link between PN and ED and on key mentalizing dimensions meaningfully relating to PN, notably through a potential role of self-mentalizing processes between PN and ED.

Narcissistic Trauma: Main Characteristics and Life Impact

ABSTRACT

Narcissistic trauma can lead to disruption of the personality functioning system. Therefore, it is important to study the persons who have it, their traits, the sphere of relationships, and strategies of social adaptation. The research aims to study narcissism indicators among individuals with narcissistic trauma diagnosed during a therapeutic conversation to identify its connection with loneliness, life satisfaction, and communication style. The empirical research involved 32 people who sought psychotherapeutic help. All participants provided written consent to participate in the research. A clinical methodology was used to identify the degree of personal narcissism-the Narcissism Assessment Test. The study of the dominant style of social interaction revealed the dominance of two opposite styles: straightforward-aggressive and responsible-generous. Thus, narcissistic trauma is likely to lead to dysfunction of the self-system, and the ability to enjoy life and communication. The data obtained can be useful for both theoretical psychologists and psychotherapists.

Treatment of Alec: "History does not have to repeat itself"

Treatment of patients with pathological narcissism presents several challenges and there is paucity of published case reports that document meaningful and durable change in patients suffering from this condition. Using descriptive and atheoretical language, this paper presents a treatment of a young man in his transition from young adulthood to middle adulthood while he was negotiating complex residues of his experiences of growing up along with developmental challenges related to work and love. Against the backdrop of these transitions, the patient was working through various aspects of functioning related to pathological narcissism. Initially, given academic pressures and past romantic disappointments, he was confronting issues related to perfectionism, self-criticism, and avoidance. While he was able to move past some of these dynamics and function academically, later challenges related to becoming an independent adult led to a retreat into an avoidant state of futility and pessimism. Working through painful family dynamics related to not being seen and controlled, along with a deepening attachment in therapy as well as confrontation with realities of his life, led him to take steps toward greater independence. Thereafter, his treatment focused on learning from life experiences such as a newly developed career and romantic life, accepting the complexity of self and others, and tolerating disillusionments.

Influence of PCDH9 (rs9540720) and narcissistic personality traits on the incidence of major depressive disorder in Chinese first-year university students: findings from a 2-year cohort study

Objective: The objective of this study was to explore the influence of the polymorphism of the protocadherin 9 (PCDH9) gene and the narcissistic personality trait (NPT) on the risk of major depressive disorder (MDD) in Chinese first-year university students. Methods: A 2-year cohort study was conducted among Chinese first-year university students who were enrolled in 2018 from two universities in Shandong Province, China. The snapshot technique was used to detect the genotypes of PCDH9 (rs9540720). The Chinese version of the Composite International Diagnostic Interview was used for the MDD assessment. The NPTs were measured by 11 items based on DSM-IV. Patient Health Questionnaire-9 and the Beck Anxiety Inventory were used to assess depressive and anxiety symptoms, respectively. Logistic regression modeling was carried out to examine the relationship between rs9540720, NPTs, and the incidence of MDD. Results: A total of 5,327 students participated in the baseline and follow-up studies and provided their blood samples. PCDH9 (rs9540720) (ORGG+GA = 2.33, 95% CI: 1.35-4.02) and NPTs (OR5-9 = 2.26, 95% CI: 1.40-3.64) increased the risk of MDD onset. There was no multiplicative interaction between NPTs and Rs9540720 (OR = 1.51, 95% CI: 0.30-7.63). Furthermore, there was no additive interaction between them (RERI = 2.40, 95% CI: -0.82-5.62; AP = 0.47, 95% CI: -0.04-0.97; and S = 2.37, 95% CI: 0.54-10.33). Conclusion: PCDH9 (rs9540720) and more NPTs are the risk factors for the incidence of MDD in Chinese first-year university students.

The effect of individual characteristics on susceptibility to aggressive and/or intimidating approaches: quantifying probability pathways by creating a victimization model

Background: A significant body of literature has identified multiple factors that contribute to established victimization by aggressive and/or intimidating behaviours. These studies primarily originate from the fields of intimate partner violence (IPV), bullying, sexual abuse, and/or commercial sexual exploitation (CSE), and generally focus on female victims. It appears, however, complicated to quantify the cumulative contribution of these factors on susceptibility to intimidating and/or hostile engagements on an individual level.Objective: To develop a comprehensive risk model to quantify, on an individual level, the cumulative effects of previously reported characteristics on susceptibility to aggressive/intimidating approaches, leading to victimization (e.g. in the context of IPV/sexual abuse).Methods: A Bayesian belief network was developed using data from previous studies, capturing the multivariate contribution of previously reported characteristics on the likelihood of becoming victimized by aggressive and/or intimidating approaches (e.g. in the IPV/CSE context) in female victims aged 12-24 years.Results: The model showed that specific combinations of characteristics may contribute to an increased likelihood of victimization (e.g. in the context of IPV/bullying/sexual abuse or CSE). This likelihood could be quantified and categorized into specific clusters of factors differentiating between victimization by physically violent, non-physical, and/or sexual aggressive/intimidating approaches.Conclusion: The present model appears to be the first to successfully quantify the cumulative contribution of individual characteristics on the likelihood of becoming victimized by aggressive and/or intimidating approaches, typically leading to victimization. Moreover, the present scientific effort and resulting model suggest that there may be a latent variable mediating between the implemented factors and overall outcome, i.e. the susceptibility to aggressive and/or intimidating approaches. From that perspective, the model may also be considered as an initial outline to effectively indicate susceptibility to such approaches.

Predicting narcissistic personality traits from brain and psychological features: A supervised machine learning approach

Narcissism is a multifaceted construct often linked to pathological conditions whose neural correlates are still poorly understood. Previous studies have reported inconsistent findings related to the neural underpinnings of narcissism, probably due to methodological limitations such as the low number of participants or the use of mass univariate methods. The present study aimed to overcome the previous methodological limitations and to build a predictive model of narcissistic traits based on neural and psychological features. In this respect, two machine learning-based methods (Kernel Ridge Regression and Support Vector Regression) were used to predict narcissistic traits from brain structural organization and from other relevant normal and abnormal personality features. Results showed that a circuit including the lateral and middle frontal gyri, the angular gyrus, Rolandic operculum, and Heschl's gyrus successfully predicted narcissistic personality traits (p < 0.003). Moreover, narcissistic traits were predicted by normal (openness, agreeableness, conscientiousness) and abnormal (borderline, antisocial, insecure, addicted, negativistic, machiavellianism) personality traits. This study is the first to predict narcissistic personality traits via a supervised machine learning approach. As such, these results may expand the possibility of deriving personality traits from neural and psychological features.

Hurting the Grandiose Self: Examining Presence, Frequency, and Functions of Nonsuicidal Self-Injury in Pathological Narcissism

The present study examines whether dimensions of pathological narcissism are associated with the presence, frequency, and function of nonsuicidal self-injury (NSSI). Adults (N = 252) completed questionnaires assessing narcissistic grandiosity, narcissistic vulnerability, fluctuation between these narcissistic states, and borderline personality disorder (BPD) symptoms. Those with a history of NSSI (n = 105) also reported the method, frequency, and function of their NSSI engagement. When controlling for co-occurring BPD symptoms, there were very few associations between vulnerability, grandiosity, and narcissistic fluctuation and NSSI presence and frequency. However, a clear pattern emerged regarding NSSI functions. Although vulnerability and narcissistic fluctuation were not associated with any functions of NSSI when co-occurring BPD symptoms were controlled for, grandiosity was positively associated with all interpersonal functions of NSSI (e.g., peer bonding, revenge) and negatively associated with the intrapersonal function of affect regulation. These results suggest a unique relationship between narcissistic grandiosity and NSSI that may inform clinical intervention.

Narcissistic Personality Disorder: Patterns, Processes, and Indicators of Change in Long-Term Psychotherapy

Change in treatment of narcissistic personality disorder (NPD) has been considered difficult to attain. Aspects of narcissistic pathology, including interpersonal enhancement, avoidance, aggressivity, and control, have contributed to challenges in forming a therapeutic alliance and pursuing treatment towards attainable goals for change and remission. This study, based on a qualitative review of therapists' case reports of individual psychotherapy with eight patients diagnosed with NPD, is the first to identify and explore patterns, processes, and indicators of change in pathological narcissism. All patients showed significant improvement in personality and life functioning, including engagement in work or education and long-term close relationships, with remission of the NPD diagnosis. The process of change was gradual, with some noticeable changes occurring in specific life contexts. Additional factors indicating and contributing to change included patients' motivation and commitment to psychotherapy, reflective ability, emotion regulation, sense of agency, and interpersonal and social engagement.

Age and gender differences in narcissism: A comprehensive study across eight measures and over 250,000 participants

Age and gender differences in narcissism have been studied often. However, considering the rich history of narcissism research accompanied by its diverging conceptualizations, little is known about age and gender differences across various narcissism measures. The present study investigated age and gender differences and their interactions across eight widely used narcissism instruments (i.e., Narcissistic Personality Inventory, Hypersensitive Narcissism Scale, Dirty Dozen, Psychological Entitlement Scale, Narcissistic Personality Disorder Symptoms from the Diagnostic and Statistical Manual of Mental Disorders, Version IV, Narcissistic Admiration and Rivalry Questionnaire-Short Form, Single-Item Narcissism Scale, and brief version of the Pathological Narcissism Inventory). The findings of Study 1 (N = 5,736) revealed heterogeneity in how strongly the measures are correlated. Some instruments loaded clearly on one of the three factors proposed by previous research (i.e., Neuroticism, Extraversion, Antagonism), while others cross-loaded across factors and in distinct ways. Cross-sectional analyses using each measure and meta-analytic results across all measures (Study 2) with a total sample of 270,029 participants suggest consistent linear age effects (random effects meta-analytic effect of r = -.104), with narcissism being highest in young adulthood. Consistent gender differences also emerged (random effects meta-analytic effect was -.079), such that men scored higher in narcissism than women. Quadratic age effects and Age × Gender effects were generally very small and inconsistent. We conclude that despite the various conceptualizations of narcissism, age and gender differences are generalizable across the eight measures used in the present study. However, their size varied based on the instrument used. We discuss the sources of this heterogeneity and the potential mechanisms for age and gender differences. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Validation of the Five-Factor Model Antagonistic Triad Measure

The personality constructs psychopathy, narcissism, and Machiavellianism, collectively described as the Dark Triad (DT), all reference socially aversive behavioral tendencies. Each construct is theorized to have features that differentiate it from others. Unfortunately, existing measures of the DT suffer from several problems. The present study compared newly developed measures of psychopathy (Super-Short Form of the Elemental Psychopathy Assessment), narcissism (Super-Short Form of the Five-Factor Narcissism Inventory), and Machiavellianism (Super-Short Form of the Five-Factor Machiavellianism Inventory [FFMI-SSF] based on the Five-Factor Model of personality)-collectively referred to as the Five-Factor Model Antagonistic Triad Measure-to existing DT inventories using a sample of undergraduate students (N = 516). As predicted, FFMI-SSF showed better divergence from measures of psychopathy and better convergence with the expert Five-Factor Model (FFM) Machiavellianism profile than did existing Machiavellianism measures. Results also demonstrated that the factors within each FFM assessment manifested differentiated correlational profiles, underscoring the utility of the multifaceted assessment of these three constructs. In addition, the use of the FFM as the basis for the new DT measures provides a pathway for the integration of DT research into the larger field of basic and clinical personality science.

What If I Feel Rejected? Borderline Personality, Pathological Narcissism, and Social Rejection in Daily Life

The authors investigate whether and how borderline and pathological narcissistic traits differ in their associations with trait and state rejection sensitivity, and with affective reactions to experiences of social rejection occurring in daily life. Community adults (N = 189) completed baseline measures of rejection sensitivity, borderline personality, and pathological narcissism, and daily measures of perceived social rejection and affective states for 7 days. Vulnerable narcissism was the main driver of negative anticipated emotions for social rejection. Borderline personality made people prone to experiencing social rejection in daily life. Moreover, borderline personality traits predicted greater self-directed aggressive impulses when experiencing social rejection. Grandiose narcissism showed only a negative association with anticipatory anxiety for rejection. These findings highlight that sensitivity to social rejection is crucial in both borderline personality and pathological narcissism.

Examining the Influence of Gender, Child Abuse, and Narcissism on Four Forms of Interpersonal Violence Among Men and Women College Students

This study examines the moderating effects of gender, child abuse, and pathological narcissism on self-reported stalking, sexual harassment, intimate partner violence, and sexual aggression in undergraduate men and women. Child abuse was positively associated with engaging in all forms of interpersonal violence for both genders. For women, pathological narcissism moderated this association such that higher levels of pathological narcissism reduced the association between child abuse and engaging in stalking, sexual harassment, sexual aggression. For men. pathological narcissism exhibited independent positive associations with engagement in sexual harassment and sexual aggression and a negative association with engagement in intimate partner violence, but no moderating effects. These gender differences have important implications for the assessment of women's violence, and university violence prevention and advocacy programs.

A Cognitive-Behavioral Formulation of Narcissistic Self-Esteem Dysregulation

Narcissistic personality disorder (NPD) is a commonly encountered diagnosis, affecting approximately 1%-6% of the population, with no evidence-based treatments. Recent scholarship has focused on self-esteem dysregulation as a key component of NPD: Excessively high expectations for oneself and how one should be treated leads to brittle self-esteem and maladaptive reactions to self-esteem threats. The current article builds on this formulation, introducing a cognitive-behavioral model of narcissistic self-esteem dysregulation that clinicians can use in providing a relatable model of change for their patients. Specifically, symptoms of NPD can be seen as a set of cognitive and behavioral habits that serve to regulate difficult emotions emerging from maladaptive beliefs and interpretations of self-esteem threats. This perspective renders narcissistic dysregulation amenable to cognitive-behavioral therapy (CBT) in which patients learn skills that help them gain awareness around these habitual reactions, reshape cognitive distortions, and engage in behavioral experiments that serve to transform maladaptive belief systems that consequently free them from symptomatic reactions. Here, we provide a precis of this formulation and examples of how CBT skills can be used to treat narcissistic dysregulation. We also discuss future research that could provide empirical support for the model and test the efficacy of CBT approaches to NPD. Conclusions focus on the notion that narcissistic self-esteem dysregulation likely varies continuously in the population and transdiagnostically across disorders. Greater insight into the cognitive-behavioral mechanisms of self-esteem dysregulation could foster tools for ameliorating distress both in people with NPD and the general populace.

Transdiagnostic Associations With Interpersonal and Affective Variability in Borderline Personality Pathology

Emotional and behavioral variability are unifying characteristics of borderline personality disorder (BPD). Ambulatory assessment (AA) has been used to quantify this variability in terms of the categorical BPD diagnosis, but evidence suggests that BPD instead reflects general personality pathology. This study aimed to clarify the conceptualization of BPD by mapping indices of variability in affect, interpersonal behavior, and perceptions of others onto general and specific dimensions of personality pathology. A sample of participants who met diagnostic criteria for BPD (n = 129) and healthy controls (n = 47) reported on their daily interactions during a 21-day AA protocol. Multilevel SEM was used to examine associations between shared and specific variance in maladaptive traits with dynamic patterns of functioning. The authors found that variability is an indicator of shared trait variance and Negative Affectivity, not any other specific traits, reinforcing the idea that BPD is best understood as general personality pathology.

Cluster B Personality Traits and Psychological Intimate Partner Violence: Considering the Mediational Role of Alcohol

The study of intimate partner violence (IPV) has evolved into more complex and integrative models to better understand the explanatory mechanisms of IPV perpetration. Nevertheless, integrative models rarely permit an in-depth analysis of a large number of relevant variables, and more specific approximations are required as basis of them. In this sense, the individual approach is the most productive research line. From the individual perspective and using data from imprisoned male offenders, the present study aimed to analyze the potential mediating role of alcohol dependence in the association of Cluster B personality traits and psychological IPV. The sample included 196 male inmates of the Penitentiary Center of Villabona (Asturias, Spain). Structural equation modeling was used to test the hypothetical and alternative models. First, model results only showed an indirect effect of antisocial and borderline personalities mediated by alcohol dependence. Nevertheless, fitting of the model to the data was poor. Second, a fully saturated model was calculated, revealing a direct effect of histrionic personality on psychological IPV. Finally, an alternative model was tested adding to first model the direct effect of histrionic personality on psychological IPV. The fitting of the alternative model to the data was good. Antisocial and borderline personalities predicted psychological IPV when mediated by alcohol dependence, while histrionic personality had a direct effect on psychological IPV. Narcissistic personality did not affect psychological IPV. These results support the hypothesis regarding the use of alcohol as a coping mechanism in antisocial and borderline individuals, acting as a disinhibitory factor which increases the likelihood of psychological IPV occurrence. Contrary to previous research, a clear direct effect of histrionic personality and psychological IPV was obtained. This association can be explained by the necessity of attention of histrionic individuals and the type (psychological) of violence studied.

A Mentalizing Approach for Narcissistic Personality Disorder: Moving From "Me-Mode" to "We-Mode"

Narcissistic personality disorder (NPD) is a prevalent condition that frequently co-occurs with other diagnoses that bring patients into treatment. Narcissistic disturbances are not often the chief complaint, but they complicate the development of an adequate therapeutic alliance. Typical countertransference challenges, combined with stigma related to NPD, result in difficulty for the therapist to relate to these patients empathically. Mentalization-based treatment provides a means for therapists to reach these patients by taking a "not-knowing" stance with interest and curiosity in clarifying and expanding a shared awareness of the patient's emotional experiences. By understanding the attachment functions, mentalizing imbalances, and problems of epistemic disregard among patients with NPD, therapists can break through the self-centered "me-mode" of the therapeutic dyad, where the typical lack of engagement or power struggles prevail, to a "we-mode," where the patient and therapist are joined in attention to what happens in the patient's mind and in interactions with others.

Self-reported narcissistic traits in patients with addiction through the lens of the ICD-11 model for personality disorders

BACKGROUND

There is a presumption that pathological narcissism, or narcissistic personality disorder per se, can be considered a precursor to addiction. Although the ICD-11 model does not distinguish specific personality disorders, narcissistic psychopathology should be captured through personality trait qualifiers.

OBJECTIVES

To verify the capacity of the ICD-11 model in the detection of narcissistic psychopathology in patients with addiction; to test its discrimination capacity, convergent validity, and specificity toward the gender and the type of addiction.

MATERIALS AND METHODS

Two samples were employed in the study. Sample 1 (n = 421) consisted of patients with addiction; Sample 2 (n = 567) consisted of general population volunteers. Age range was 18-75 years and a battery of self-assessment questionnaires containing Personality Inventory for DSM-5-Brief Form Plus Modified; Triarchic Psychopathy Measure; Hypersensitive Narcissism Scale; and Level of Personality Functioning Scale-Self-Report was administered by pencil-and-paper method.

RESULTS

The following was confirmed: (1) capacity of the ICD-11 model in relation to capture narcissistic pathology; (2) the differentiation capacity between the clinical and non-clinical population; (3) gender specificity in relation to grandiose and vulnerable narcissism; (4) the connection between the overall degree of impairment in personality functioning and most of trait qualifiers; (5) certain specifics of patients with addiction in relation to the type of addiction.

CONCLUSION

Results support the empirical and clinical relevance of the ICD-11 model in capturing narcissistic pathology in addicted patients. Clinical implications concerning assessment and treatment in addiction settings, and certain limits regarding the Anankastia domain are discussed.

The Alleged Epidemic of Social Narcissism: Implications for Nurse Leaders

Research indicates that narcissistic personality disorder and subclinical narcissism may be reaching epidemic proportions within American society. It is thus probable that nursing administrators will encounter narcissistic behavior among their staff, supervisors, and/or patients and patient family members. It is therefore crucial that nurse leaders understand the causes of narcissism and how narcissistic behaviors might be addressed within health care settings. An awareness of these issues can help decrease the damage that narcissistic behaviors can have on individuals and institutions.

Developing and Validating the Narcissistic Personality Scale (NPS) among Older Thai Adults Using Rasch Analysis

Background: Being older could be stressful, especially among people with narcissistic personality disorders. Nevertheless, the tool is yet to be available among older Thai individuals. The study aimed to develop a tool to detect symptoms of narcissistic personality, and to validate its psychometric properties among older Thai adults. Methods: The Narcissistic Personality Scale (NPS) was developed based on nine domain symptoms of narcissistic personality disorder from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), consisting of 80 items. The original scale was field-tested using Rasch analysis for item reduction, rendering a final 43 items. NPS was further investigated among 296 seniors aged 60 years old. Rasch analysis was used to assess its construct validity. Result: Of 43 items, 17 were further removed as infit or outfit mean square >1.5. The final 26-item NPS met all necessary criteria of unidimensionality and local independence without differential item functioning due to age and sex, and good targeting with subjects. Person and item reliability were 0.88 and 0.95, respectively. No disordered threshold or category was found. Conclusions: The NPS is a promising tool with a proven construct validity based on the Rasch measurement model among Thai seniors. This new questionnaire can be used as outcome measures in clinical practice.

The relationship of narcissism with tendency to react with anger and hostility: The roles of neuroticism and emotion regulation ability

The present study examined the relationship of grandiose and vulnerable narcissism with dispositional anger and hostility. We investigated the roles of neuroticism, emotional intelligence, and gender in this relationship, using a sample of 405 participants. The results indicated that vulnerable narcissism was associated with a higher tendency toward anger and hostility, and that neuroticism accounted for a large part of this association. Poor emotion managing, known as strategic emotion regulation ability, also played a role in hostility related to vulnerable narcissism, especially among men. When emotional stability was controlled for, grandiose narcissism showed links to anger and hostility. We concluded that high neuroticism and poor emotion regulation abilities among vulnerable narcissists contribute to increased anger/hostility, whereas emotional stability likely protects grandiose narcissists against these internal aspects of aggression. The significant relationships between both forms of narcissism with aggression, remaining after neuroticism and emotion regulation were accounted for, suggest that there is another underlying source of this link. Finally, we found that controlling for interindividual differences in neuroticism significantly increased the relationship between vulnerable and grandiose narcissism, suggesting the existence of the common core of narcissism.

The relation between narcissism and aggression: A meta-analysis

OBJECTIVE

Narcissism is a complex, hierarchical construct that can be studied at the one, two, or three factor levels with different components within each level having their own unique nomological networks. The manner in which narcissism-both broadly and narrowly construed-is linked to aggression is important to understand given longstanding clinical and empirical observations of a link between the two and the critical implications of aggression.

METHODS

The current preregistered meta-analysis (k = 118) took a novel methodological approach in exploring the association between the three levels of narcissism (i.e., global construct level, dual-dimension level, trifurcated level) and three indices of aggression (i.e., general, proactive, reactive).

RESULTS

Results revealed that the global construct of narcissism shows a moderate positive association with different indices of aggression. Vulnerable narcissism associated strongly and positively with reactive aggression and general aggression. At the trifurcated level, interpersonal antagonism associated positively with all indices of aggression, agentic extraversion associated negatively with all indices of aggression, and narcissistic neuroticism associates positively with general and reactive aggression.

CONCLUSION

The study highlighted the importance of studying narcissism, and potentially other personality profiles, at a finer-grained level to better understand crucial psychological processes associated with the construct of interest.

Female Narcissism: Assessment, Aetiology, and Behavioural Manifestations

Despite putative gender differences in the expression of narcissism, prominent theories have virtually dismissed the role of females in the development and manifestation of narcissism. The contention that narcissism is a pathology of the self that may partly differ in males and females is further evident in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 reports that up to 75% of those diagnosed with Narcissistic Personality Disorder (NPD) are men. Such figures suggest that the representation of narcissism as codified in the DSM-5 may only be marginally applicable to females, given its prominent focus and nature on capturing grandiose themes which closely resemble commonly masculine norms. The overemphasis on grandiose features extends to the empirical literature which defines narcissism as a normative personality trait and is widely assessed using the Narcissistic Personality Inventory (NPI), on which males obtain significantly higher scores than females. As this review will demonstrate, one limitation frequently occurring in the literature is the attempt to comprehend narcissistic manifestations in females through the lens of what has commonly been defined as narcissism (DSM/NPI). In this review, the literature concerning the diagnostic assessment and conceptualisation of narcissistic personality disorder, aetiological factors, aggression, and partner violence perpetration will be discussed in relation to the importance of gender. This is followed by a review of existing gaps in theory and research, and suggestions for fruitful directions that can aid a richer and more meaningful literature on narcissism inclusive of gender issues.

Transference-Focused Psychotherapy for Pathological Narcissism and Narcissistic Personality Disorder (TFP-N)

In this article, we provide an overview of transference-focused psychotherapy for patients with pathological narcissism and narcissistic personality disorder (TFP-N). In TFP-N we have modified and refined the tactics and techniques of TFP, an evidence-based treatment for borderline personality disorder, to meet the specific challenges of working with patients with narcissistic personality pathology whose retreat from reality into an illusory grandiosity makes them particularly difficult to engage in treatment. We first describe a model of narcissistic pathology based on considerations of psychological structure stemming from object relations theory. This model provides a unifying understanding of the core structure of narcissistic pathology, the pathological grandiose self, that underlies the impairments in self and interpersonal functioning of those with narcissistic pathology across the levels of personality organization (from high functioning to borderline to malignant). We then delineate the clinical process of working with patients with pathological narcissism and narcissistic personality disorder. Starting with the assessment process, using a detailed clinical example, we guide the reader through the progression of TFP-N as it helps the patient move from the distorted, unintegrated sense of self underlying the narcissistic presentation to the more integrated, realistic sense of self that characterizes healthier personality functioning. In TFP-N the focus on the disturbed interpersonal patterns of relating in the here and now of the therapeutic interaction is the vehicle to diminish grandiosity and improve relatedness, thereby effecting enduring changes in mental representation and real-world functioning.

Self-serving social strategies: A systematic review of social cognition in narcissism

Narcissistic Personality Disorder is characterised by inflated self-importance, an excessive need for admiration, and a lack of empathy. The interpersonal difficulties associated with narcissistic personality may be becoming more widespread given its increasing prevalence within the general population. This systematic review investigated the relationship between narcissistic personality traits and social cognition (i.e. theory of mind; emotion recognition; empathy; emotional intelligence) in clinical and non-clinical samples. Cognitive empathy (i.e. perspective taking) appears unlikely to be impaired, while affective empathy (relating to another’s emotion state) may be reduced in association with narcissism. Those with grandiose narcissism rate their empathic skills more highly than those with vulnerable narcissism, but concurrent administration of objective measures is rare, limiting insight into the validity of self-ratings. Rather than deficits in aspects of social cognition, the overall pattern could reflect motivation, or advantageous use of social cognitive skills to serve the self. Indeed, interpersonal strategies associated with narcissism (e.g. deception; manipulation) suggest the application of understanding another’s beliefs or desires in the context of low empathy. Further research should seek to explore performance on a wider range of emotion recognition and theory of mind tasks, and whether characteristics such as excessive jealousy and paranoia could reflect hyper-mentalizing.

Narcissism and Exercise Addiction: The Mediating Roles of Exercise-Related Motives

The present research examined whether the associations that narcissistic personality features had with exercise addiction were mediated by particular motives for engaging in exercise in a large Israeli community sample (N = 2629). The results revealed that each aspect of narcissism was positively associated with exercise addiction. Narcissistic admiration and narcissistic rivalry had similar positive indirect associations with exercise addiction through the interpersonal motive for exercise. However, these aspects of narcissism diverged in their indirect associations with exercise addiction through psychological motives, body-related motives, and fitness motives for exercise such that these indirect associations were positive for narcissistic admiration but negative for narcissistic rivalry. Narcissistic vulnerability had positive indirect associations with exercise addiction through body-related motives and fitness motives that were similar to those observed for narcissistic admiration. These results suggest that exercise-related motives may play important roles in the associations that narcissistic personality features have with exercise addiction. The discussion will focus on the implications of these results for understanding the complex connections between narcissism and exercise addiction.

Fifty Shades of Darkness: A Socio-Cognitive Information-Processing Framework Applied to Narcissism and Psychopathy

Existing trait-based and cognitive models of psychopathy and narcissism fail to provide a comprehensive framework that explains the continuum between sub-clinical and clinical presentations of those personalities and to predict associated maladaptive behavior in different social and cultural contexts. In this article, a socio-cognitive information-processing framework for narcissism and psychopathy (SCIPNP) is proposed to explain how psychopathic and narcissistic schemata influence the activation of psychological processes that interact with social and cultural contexts to display those personalities at a sub-clinical level. The proposed framework enables us to predict maladaptive behavior and to explain how sub-clinical narcissists and psychopaths develop personality disorders. The SCIPNP emphasizes the role of culture in shaping motives, appraisals, behavior and affect. Recommendations for future research are provided.

Meta-Analysis of white matter diffusion tensor imaging alterations in borderline personality disorder

Borderline personality disorder (BorPD) is characterized by instability and mood dysregulation, unstable relationships and distorted self-image. Identification of underlying anatomical and physiological changes is crucial to refine current treatments and develop new ones. In this perspective, previous magnetic resonance imaging studies have highlighted alterations associated with BorPD phenotype. In particular, diffusion-weighted imaging/Diffusion tensor imaging (DWI/DTI) has identified many white matter structural alterations in individuals with this diagnosis. Although in its infancy, limiting this line of investigation is a lack of direction at the field level. Hence, the present paper aims to conduct a meta-analysis of DWI/DTI findings in individuals with a diagnosis of BorPD, testing the hypothesis that there are specific white matter alterations associated with BorPD. To this end, we performed a meta-analysis of the existing literature of DWI/DTI in BorPD representing a total of 123 individuals with BorPD and 117 Controls. Our results indicated that individuals with BorPD show regions of reduced fractional anisotropy in the corpus callosum and fornix. These results survived all jack-knife reshuffles and showed no publication bias. This suggests that alterations in these structures may contribute to psychopathology. Further, the present results lend support to extant psychological and biological models of BorPD.

Features, State and Context of Narcissism in Drug Misuse

Both clinical and street-based encounters with people who misuse drugs have led the authors to examine the relationship between misuse of drugs and narcissism. Widely accepted criteria for diagnosing Substance Use Disorder (SUD) suggest parallels between narcissistic traits (e.g. invulnerability to consequences and lack of empathy for others) and the characteristics of drug abusers. Because narcissism as a concept has a long and somewhat confusing history, we first reviewed its origins in the psychoanalytic tradition of psychiatry and its exegesis into current clinical concepts in order to arrive at a set of attributes that may be useful when applied to problems of drug abuse. This process required extensive review of the literature on narcissism and its interactions with the literature on drug abuse. This process led to an understanding that positive self-concept may exemplify a variety of socially beneficial narcissism, but that at the other end of narcissism's continuum of traits may be found exploitative and non-empathetic traits. Furthermore, the negative traits of narcissism, as they may arise in adolescence along with drug use, can support an individual's ongoing dependence on drugs, especially if narcissism and drug use persist into adulthood. Our investigation of narcissism and drug use revealed, through in-depth interviewing, that some drug users employ drugs and alcohol to feed their self-concepts of superiority over other people. Our findings suggest that treatment for drug abuse cannot proceed assuming that drug users have low self-concepts. Rather, their continued use of drugs may emanate from a narcissistic sense of superiority.

Pathological Narcissism: A Study of Burden on Partners and Family

Pathological narcissism is characterized by impaired interpersonal functioning, but few studies have examined the impact of the disorder on those living in a close relationship. Participants (N = 683; comprising romantic partners [77.8%], mothers [8.5%] or other family members [10%]) in a close relationship with a relative with pathological narcissism completed measures assessing levels of grief, burden, mental health, and coping style. Participants' reported burden was over 1.5 standard deviations above comparison carers of people with mood, neurotic, or psychotic disorders, and higher than carers of people with borderline personality disorder. Similarly, caseness for depression (69% of sample) or anxiety disorders (82%) in the sample was high. Relationship type, subtype expression (vulnerable/grandiose), and coping style were all found to significantly relate to experienced psychopathology. Although limitations exist regarding sample selection that may influence interpretation of results, these findings quantify the significant interpersonal impact of pathological narcissism in this sample.

Early implicit-explicit discrepancies in self-esteem as correlates of childhood depressive symptoms

This longitudinal study examined early social-cognitive markers that might be associated with the emergence of childhood depression and anxiety. At 5 years of age, 137 children completed an implicit self-esteem measure. At 9 years of age, the same children completed measures of implicit self-esteem, explicit self-esteem, depression, and anxiety. Two novel findings emerged. First, higher implicit self-esteem at age 5 than explicit self-esteem at age 9 (implicit > explicit discrepancy) was associated with depressive symptoms at age 9, but not with symptoms of anxiety. Second, this cross-age implicit > explicit discrepancy was associated with depressive symptoms more strongly than was the same implicit > explicit discrepancy measured concurrently at age 9. The overall pattern suggests that the appearance of depressive symptoms in children is associated with discrepancies between implicit and explicit self-esteem and not just lower levels of implicit self-esteem or lower levels of explicit self-esteem taken alone. It is the direction and discrepancy across time that is particularly informative, such that discrepancies between early implicit representations and later explicit reports of self-worth reflect a developmental pathway associated with elevated risk for depressive symptoms. Taken altogether, this study illustrates the benefits of combining work in developmental, child-clinical, and social psychology to provide a more complete view of the developing child. We believe that combining implicit and explicit measures of self-esteem across developmental time points can be used to examine early markers of depression in children at younger ages than typically possible with explicit measures alone.

Narcissism and Quality of Life: The Mediating Role of Relationship Patterns

Pathological narcissism is associated with decreased quality of life, even when accounting for psychiatric comorbidity, but the processes behind this association are unclear. Here, we evaluate whether disturbed relatedness accounts for the negative association between narcissistic pathology and quality of life. Patients in day hospital treatment for personality pathology (N = 218, 70% female; mean age, 37.3 years) completed measures of personality disorder features, quality of life, and global symptoms before beginning treatment. Quality of object relations was assessed through semistructured interviews. Regression-based mediation analyses showed that narcissistic personality traits relate to quality of life through quality of object relations, controlling for other personality disorders and psychiatric distress. These results highlight the importance of problematic relationship patterns for the low quality of life associated with pathological narcissism. Clinicians working with narcissistic individuals should consider psychotherapies that promote mature relatedness and should attend to facilitating the quality of patients' relationships.

Therapeutic implications of personality disorders in dermatology

There is a significant psychiatric comorbidity that exists in multiple dermatological conditions, stemming from the patient''s own psychological make up. This article reviews personality disorders and their types, which influence the course and prognosis of several psychodermatological disorders. Self-inflicted skin lesions, for example, are usually associated with obsessive-compulsive behavior, but they also share connections to Narcissistic and Borderline personality disorders. Body dysmorphic disorder is another psychodermatological condition seen in dermatology, aesthetic, and cosmetic surgery clinics, which is influenced by patient's personality type. In general, there is a significantly high proportion of personality disorders seen in aesthetic and cosmetic surgery. The management of patients with personality disorders is challenging, but joint liaison between psychiatry and dermatology has proven helpful and can provide patients with the best care for their psychological needs and dermatologic care.

Strangers in a Strange Land: How Our Founding Principles and a Bitter Pill Undo the Assimilation of US Catholics

Most Catholic physicians work with the comfortable assumption that we can practice our profession and our faith, fully assimilated into modern American culture and society. Increasingly, we have come to realize that to be a Catholic Christian is by nature to be countercultural. American culture, ordered by the founding fathers in concepts of liberty and freedom, has been profoundly affected by the introduction and reliance on a contraceptive pill. This has changed the mores and sexual behaviors of society in ways that are antithetical to Catholic values. The consequences of contraception have directly led to an acceptance of a broad number of behaviors and attitudes that society insists must be tolerated. This challenges the commitments of Catholic physicians both personally and professionally.

On the uses and abuses of narcissism as a public health issue

Psychiatry understands narcissism as a pathological condition associated with poor social outcomes and difficulty relating to others. Millennials have been depicted by psychological research as 'narcissistic', and the term has lost accurate meaning. We underline the intellectual laxity of conflating social changes with narcissism and suggest ways forward.

Sexual Coercion by Women: The Influence of Pornography and Narcissistic and Histrionic Personality Disorder Traits

Largely overlooked in the literature, this study investigated factors influencing women's use of sexual coercion. Specifically, pornography use and personality disorder traits linked with poor impulse control, emotional regulation, and superior sense of sexual desirability were considered. Women (N = 142) aged 16-53 years (M = 24.23, SD = 7.06) were recruited from community and student populations. Participants completed the Narcissistic and Histrionic subscales of the Personality Diagnostic Questionnaire-4, in addition to the Cyber-Pornography Use Inventory to explore the influence of their pornography use (interest, efforts to engage with pornography, and compulsivity) on their use of sexual coercion. This was measured using four subscales of the Postrefusal Sexual Persistence Scale: nonverbal sexual arousal, emotional manipulation and deception, exploitation of the intoxicated, and use of physical force or threats. Multiple regression analyses revealed that pornography use, narcissistic traits, and histrionic traits significantly predicted the use of nonverbal sexual arousal, emotional manipulation and deception, and exploitation of the intoxicated. Effort to engage with pornography was a significant individual predictor of nonverbal sexual arousal and emotional manipulation and deception, while histrionic traits were a significant individual predictor of exploitation of the intoxicated. Findings were discussed in relation to existing sexual coercion literature and potential future research.

Clinician Emotional Responses and Therapeutic Alliance When Treating Adolescent Patients With Narcissistic Personality Disorder Subtypes: A Clinically Meaningful Empirical Investigation

This study examined clinician emotional responses and therapeutic alliance in psychotherapy with adolescent patients with specific subtypes of narcissistic personality disorder (NPD). A national sample of therapists (N = 58) completed the Therapist Response Questionnaire for Adolescents to identify patterns of clinician response, the Working Alliance Inventory to evaluate the quality of alliance, and the Shedler-Westen Assessment Procedure-II for Adolescents to assess the personality pathology of a patient in their care. The results showed that the grandiose narcissistic subtype was positively related to angry/criticized and disengaged/hopeless therapist responses and negatively related to warm/attuned response. The fragile subtype was positively related to overinvolved/worried therapist response. The high-functioning/exhibitionistic subtype was negatively related to angry/criticized response. Lower quality of therapeutic alliance was positively associated with the grandiose subtype. Moreover, the empirically founded prototypes of therapist responses to adolescent patients with NPD subtypes strongly resemble theoretical-clinical accounts. The clinical implications are addressed.

Dos and Don'ts in Treatments of Patients With Narcissistic Personality Disorder

This article identifies guiding principles in effective psychotherapies of patients with narcissistic personality disorder (NPD) and cautions against some common pitfalls. Individual psychotherapies of NPD patients were examined by both authors, who tested whether or not some principles, recommended in the literature, effectively promote these therapies and help these patients in moving forward with their lives and with effective therapy use. The authors identify a number of principles that were associated with more positive therapy development: helping patients identify goals and direction of their therapies, promoting a sense of agency, promoting a shift of focus to sense of vulnerability, and anticipating difficulty in developing and maintaining the treatment alliance. Common mistakes in these treatments are engaging in a power struggle with the patient, overindulging the grandiosity of the patient, directly challenging the grandiosity of the patient, and ignoring treatment-interfering behaviors. Identification of principles of effective therapies with NPD patients can help with the development of more effective treatment approaches for NPD.

Transference-Focused Psychotherapy for Narcissistic Personality Disorder: An Object Relations Approach

Transference-focused psychotherapy (TFP) is an empirically validated psychodynamic psychotherapy for borderline personality disorder (BPD), based on object relations theory, that has clinical utility for individuals with narcissistic personality disorder (NPD). Given the effectiveness of TFP for patients with BPD, including a number of patients with comorbid NPD, we have adapted the tactics and techniques of TFP with specific modifications for patients with NPD or narcissistic traits. TFP for NPD (TFP-N) retains core elements of the treatment, including a contracting phase and an interpretive process designed to identify and modify maladaptive mental representations of self and others that underlie the affect and behavioral dysregulation in those with personality disorders including NPD. The major goal of TFP-N is the focus on disturbed interpersonal patterns of relating in the here-and-now of the therapeutic interaction as a vehicle to effect enduring changes in personality organization and real-world changes in the areas of love and work.

Mentalization-Based Treatment for Pathological Narcissism

Despite the growing cultural and empirical interest in pathological narcissism (PN), effective treatment guidelines for PN have not yet been established. This article develops mentalization-based treatment (MBT), a leading evidence-based therapy for borderline personality disorder, as a primary intervention for PN. Synthesizing research on parenting styles, attachment patterns, and empathy in PN, the authors propose a developmental model of narcissism centering on impairments in mentalization. Core therapeutic techniques of MBT for PN are outlined, including clinical examples to illustrate practical implementation. As an accessible, easy-to-operationalize, and resource-sensitive therapeutic approach, MBT offers considerable promise for future empirical investigation and clinical applications in the treatment of patients with pathological narcissism.

Living with pathological narcissism: a qualitative study

BACKGROUND

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.

METHOD

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.

RESULTS

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.

Characterological depression in patients with narcissistic personality disorder

Background: Depressive symptoms often occur in patients with personality disorders. Along the lines of the precious concepts of reactive and melancholic forms of depression, two different patterns of depressive symptoms can be identified. Reactive forms of depression is considered to be related to dysfunction of emotional regulation and social functioning, and to personality disorders. This study aimed at exploring the pattern of depressive symptoms in patients with Narcissistic Personality Disorder (NPD) compared to a group of depressed patients without Personality Disorder (PD). The Newcastle Diagnostic Depression Scale (NDDS) is a clinical instrument designed to differentiate reactive depression from melancholic depression. Method: The study investigated patterns of depressive symptoms in 117 out-patients, divided into two groups. One group containing 56 patients with depressive symptoms by no PD and the other group comprised of 61 patients with depressive symptoms and NPD. The participants were interviewed using the Newcastle Diagnostic Depression Scale. Results: There was a significant difference between the groups, as the NPD group suffered from reactive forms of depression. The NPD group showed a pattern of depressive symptoms characterized by fluctuation of the depressive state, without time demarcation of depressive episode, ruminations preoccupied with hostility and accusatory feelings towards other, but not self-accusatory feelings, fluctuation suicidal ideation triggered by external events accompanied by parasuicidal behavior, lack of neuro-vegetative symptoms such as insomnia with early wakening, loss of appetite and weight loss. The No PD group showed the opposite pattern. Conclusion: Based on these results NDDS is considered to be an applicable instrument for identifying personality pathology in patients with depressive symptoms, by recognizing the specific pattern. This is thought to be important for adequate treatment planning.

Addiction and the Dark Triad of Personality

In this article, we review associations between the Dark Triad of personality (narcissism, Machiavellianism, and psychopathy) and addictive behaviors, both substance-related and non-substance-related. We summarize evidence from personality and clinical research and integrate it with prevailing models of addiction. Specifically, we discuss addictive behavior in the light of affect regulation, which is likely more relevant in narcissism, as well as inhibitory deficits, a putative mechanism in psychopathy. These mechanisms can be related to central motives of the respective personality constructs, such as stabilization of self-esteem in narcissism and impulsive stimulation seeking in psychopathy. We conclude that different mechanisms might lead to similar observable behavior in narcissism and psychopathy at earlier stages of the addiction cycle, but psychopathic disinhibition might be particularly relevant at later stages. This underpins the importance of considering personality factors for the understanding and treatment of addiction.