Narcissism is extremely popular in both the social and clinical psychology realms as well as in everyday terminology. Many understand narcissism to describe those who are too interested in themselves or have an inflated ego. While there is some truth to this, there is more to the story.
Those with narcissism do not necessarily have higher self-esteem or more intense insecurities than those without narcissism.
A more accurate representation of those with narcissism is “a pattern of grandiosity, need for admiration, and lack of empathy” (American Psychiatric Association, 2013, p. 645).
However, there remains a debate over whether to view narcissism from a clinical or social-psychological perspective (Foster & Campbell, 2007).
The clinical and social psychology concepts of narcissism share many similarities, but they differ in one important aspect. In clinical psychology, narcissism is a personality disorder (Foster & Campbell, 2007).
Based on diagnostic criteria, individuals either have narcissistic personality disorder or do not. Put differently, the structure of clinical narcissism is categorical.
In contrast, social psychologists generally view narcissism as a dimension. According to this view, there is no categorical property to the structure of narcissism.
There exists no point along the narcissism continuum where one shift from ‘‘normal’’ to ‘‘narcissist.” Despite the ongoing debate, for the sake of clarity, this article will focus primarily on the clinical aspect known as narcissistic personality disorder (NPD).
In This Article
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) categorizes narcissism as a personality disorder that is “dramatic, emotional, or erratic” (American Psychiatric Association, 2013, p. 646).
Such individuals “experience very intense emotions or engage in extremely impulsive, theatrical, promiscuous, or law-breaking behaviors” (Salters-Pedneault, 2020).
The diagnostic criteria for NPD, according to the DSM-5, are as follows:
- “Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
- Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
- Believes that he or she is ‘special’ and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
- Requires excessive admiration.
- Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
- Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
- Lacks empathy is unwilling to recognize or identify with the feelings and needs of others.
- Is often envious of others or believes that others are envious of him or her.
- Shows arrogant, haughty behaviors or attitudes” (American Psychiatric Association, 2013, p. 669-670)
To be diagnosed with NPD, an individual must exhibit five or more of the above symptoms (American Psychiatric Association, 2013).
Furthermore, to be diagnosed, individuals must display “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…” (American Psychiatric Association, 2013, p. 669).
Although there is somewhat of a debate over how many types of narcissism there are, this article will focus on two subclinical subtypes: covert vulnerable and overt grandiose narcissism.
The two share many characteristics; however, they express themselves in very different ways as well.
Overt Grandiose Narcissism
Overt grandiose narcissism is “characterized by extraversion, low neuroticism, and overt expressions of feelings of superiority and entitlement” (Brogaard, 2019, p.1).
Those who are characterized as having overt grandiose narcissism believe they are superior to their peers and that they deserve special treatment. They expect others to cater to their every need.
These types of narcissists generally have good social skills and are hard-working because they strongly desire to be successful. They can become obsessed with wealth and power and focus on getting others to like them.
Covert Vulnerable Narcissism
On the other hand, covert vulnerable narcissism is quite different in some areas. According to Broggard (2019, p. 2), covert vulnerable narcissism “reflects introversive self-absorbedness, high neuroticism, hypersensitivity even to gentle criticism, and a constant need for reassurance.”
This is the type of narcissism rarely thought of or described in the media today. An individual with this subtype of NPD typically has characteristics such as being generally fragile and introverted.
People with covert vulnerable narcissism also believe they are better than others. Still, one of their defining characteristics is that they severely fear criticism and can even appear panicked when criticized.
Due to these characteristics, these types of narcissists generally are less successful than their overt counterparts but still imagine themselves as having impressive achievements or high statuses.
These narcissists often suffer from depression and self-pity when criticized and generally struggle to trust others. They often desire others’ possessions or positive attributes and show disregard for others (Emerton, 2020).
There are thought to be two main causes of NPD, although they still are not well understood: genetics and environmental factors. Many studies on twins have found that genes most likely play a role in the development of NPD (Cain et al., 2008).
Besides genes, many environmental factors are thought to play a role as well. A majority of the causes occur in childhood.
Some examples are abuse or neglect, overly high expectations from parents, trauma, rejection, and unpredictable care or neglect (Brazier, 2020). It is also thought that stress can worsen the symptoms of NPD, which may be a causal factor for the disorder.
Although treatment for those with NPD can be difficult because these individuals generally do not believe they have a problem, there are options.
The first line of defense, and often best, is psychotherapy. Although the literature on psychotherapy and NPD is still developing, there are several different types of psychotherapy used to treat NPD, some of which have been adopted from treatments for borderline personality disorder.
Transference-focused psychotherapy (TFP) can be a great option for those with NPD (Tartakovsky, 2017). This psychodynamic therapy, a type of therapy that “focuses on unconscious processes as they are manifested in a person’s present behavior” (Substance Abuse and Mental Health Administration, 1999, p. 1), focuses on the relationship between the clinician and client as well as the client’s relations with the outside world.
The treatment begins with a verbal contract between the two, laying out each member’s roles and responsibilities during treatment. Both the clinician and the client work together to navigate through any issues the client has.
Another option for those with NPD is schema-focused therapy (Tartakovsky, 2017). This therapy combines psychodynamic therapy with cognitive behavioral therapy (CBT), which is “a short-term, goal-oriented psychotherapy treatments…” whose goals are to “…change patterns of thinking or behavior that are behind people’s difficulties, and so change the way they feel” (Martin, 2016, p.1).
Schema-focused therapy helps replace unhealthy schemas (how the client organizes and interprets information) (Cherry, 2019; Tartakovsky, 2017).
Mentalization-based therapy (MBT) can be helpful for those with NPD as well (Tartakovsky, 2017). This psychodynamic treatment helps those with NPD better reflect on their thoughts as well as the thoughts of others.
Also, dialectal behavioral therapy (DBT) has been proven to be very effective for many disorders, including NPD. This form of CBT “focuses on mindfulness, emotional regulation, distress tolerance, and relationship skills” (Tartakovsky, 2017, p. 2).
A type of therapy specifically designed to treat individuals with NPD is metacognitive interpersonal therapy (MIT). In MIT, there are two stages: stage setting and change promoting.
Stage setting involves “gaining a deeper understanding of the person’s interpersonal relationships by exploring different situations, memories, and recurrent patterns,” while change promoting “includes showing individuals that their ideas do not necessarily mirror reality and that situations can be understood differently when seen from another angle, along with building new and healthier ways of thinking, feeling, and behaving” (Tartakovsky, 2017, p. 2)
The final therapy typically used to treat NPD is called supportive psychotherapy. It combines psychodynamic therapy and CBT. Supportive psychotherapy’s goals include stabilizing the individual, addressing comorbid conditions, and, given the condition the patient is in, attaining the highest possible level of functioning (Tartakovsky, 2017).
In more severe cases of NPD, medication may be required as well. Clinicians may prescribe mood stabilizers, antipsychotics, or antidepressants to treat those with NPD.
However, individuals with NPD often struggle to take their prescribed medications because they tend to be highly sensitive to the side effects of their medication (Tartakovsky, 2017).
Dealing with Someone With NPD
Being in a personal relationship with someone who has NPD can be challenging; however, it is possible. Here are a few steps to take when interacting with someone with NPD.
One of the first steps is to avoid taking any particularly negative interactions with the individual personally (Clarke, 2020). This can be difficult given the individual’s lack of empathy, sense of entitlement, deceptive behaviors, and manipulative patterns.
However, it is critical to keep this step in mind when dealing with someone with NPD. The individual with NPD has a disease, and often their actions are caused by the disease and are not focused on another individual.
Another key step to take is to set boundaries. Those with NPD often do not have healthy boundaries (Kacel et al., 2017). Although it can be scary and difficult, setting boundaries lets those with NPD understand that the person who cares for them has strong personal values.
Taking care of oneself is important as well. Try practicing yoga, meditation, getting enough food and rest, or doing things one enjoys. It’s important to take care of oneself first before one can take care of one another.
If the relationship becomes too stressful to self-manage, individuals are encouraged to seek help. Psychotherapy may help set and maintain boundaries, navigate stress, and feel validated.
If none of these steps are working effectively, then the last option available is to end the relationship. This can be an especially important step if the relationship is unhealthy or abusive. It is important to self-reflect and be honest. If need be, taking a step back may be the best option.
The best way to measure narcissism is still up for debate. There are many options to do so. Some use the Thematic Apperception Test (TAT) to assess for NPD.
Sometimes known as the “picture interpretation technique,” TAT is a projective test developed in the 1930s at Harvard University by American psychologists Henry A. Murray and Christina D. Morgan (Cherry, 2020).
This means that a series of ambiguous scenes, words, or images are presented, and individuals’ responses to these stimuli are recorded and analyzed.
A popular example of the TAT is instructing an individual to tell a dramatic story after viewing a series of picture cards showing several ambiguous characters, scenes, and situations.
The TAT, in its complete form, consists of 31 different cards, although Murray originally recommended using only 20 of them and choosing cards that revealed characters similar to the topic at hand.
Today, practitioners use between five and 12 cards typically chosen because the professional believes that the scene depicted matches the client’s needs or situation.
One of the main criticisms of TAT is that there is no standardized scoring system. Murray recommended a complex one, but many practitioners have chosen not to use it and subjectively interpret the results themselves. Furthermore, there are various ways in which clinicians administer the test. All of this variability has led to some scrutiny over TAT.
Another option that practitioners have used to measure NPD is the Rorschach inkblot test. The Rorschach inkblot test, another type of projective test, was created by Hermann Rorschach in Switzerland in 1995 (Cherry, 2020).
The test is most commonly used to assess personality and emotional functioning. In Psychodiagnostik, a 1921 book published by Rorschach, he identified ten inkblots useful for diagnostic purposes. In practice, these black, white, gray, and sometimes colorful inkblots are shown to the client and asked to interpret what image they are being shown.
In this book Psychodiagnostik, Rorschach described how to score the test as well. Since then, many other scoring systems have been developed and are commonly used today.
The common threads among the scoring systems are scales assessing how participants describe the image, how long they take to respond, extra or unrelated comments spoken, and the originality of the responses given.
Similar to the TAT, though, the Rorschach test has a wide variability in its standardization of ways in which the test is administered and in its scoring systems. This has led to poor validity and reliability surrounding the test.
There are several other ways to assess for NPD as well. Some use linguistic clues like first-person singular nouns in conversation and written components (Konrath et al., 2014). Others use tests such as the Diagnostic Interview for Narcissism. This interview technique evaluates the five major domains of function: “interpersonal relations, reactiveness, affects and moods, grandiosity, and social and moral adaptation” (Gunderson et al., 1990, p.1).
However, despite this wide array of assessments, the most common way to measure NPD is through self-report measures. An example of one of these self-report measures is The Millon Clinical Multiaxial Inventory (MCMI-III). The MCMI-III measure is used to detect NPD and was developed by Theodore Million.
It is made up of 175 true-false questions (Axelrod, 2016). Typically, the MCMI-III takes clients around 30 minutes to complete this test. Upon completion, the test produces 24 personality and clinical scales, which assess for NPD, and five scales used to verify how the person took the test.
Of these popular self-report assessments, though, the most common is the Narcissistic Personality Inventory (NPI). This test measures overt and grandiose aspects of narcissism (Konrath et al., 2014).
The test contains 40 different self-choice statements, such as “If I ruled the world, it would be a better place” or “The thought of ruling the world frightens the hell out of me” (Konrath et al., 2014, p. 3).
Once a client reaches a certain threshold on the NPI scale, they are then determined to have NPD. Lastly, there are several other self-report measures that assess for NPD as well, such as the Hypersensitive Narcissism Scale (HSNS), the Five Factor Inventory Scale (FFNI), and the Pathological Narcissism Inventory (PNI).
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