Practices of Claiming Control and Independence in Couple Therapy With Narcissism

This review documents two themes of emphasis found in phenotypic descriptions of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clinical theories of narcissism spanning 35 years consistently describe variations in the expression of pathological narcissism that emphasize either grandiosity or vulnerable affects and self-states. Recent research in social/personality psychology examining the structure of narcissistic personality traits consistently finds two broad factors representing Grandiosity-Exhibitionism and Vulnerability-Sensitivity-Depletion respectively. However, the majority of psychiatric criteria for narcissistic personality disorder (NPD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) emphasize expressions of grandiosity. By placing most of the diagnostic emphasis on overt grandiosity, DSM NPD has been limited by poor discriminant validity, modest levels of temporal stability, and the lowest prevalence rate on Axis II. Despite converging support for two phenotypic themes associated with pathological narcissism, psychiatric diagnosis and social/personality psychology research often focus only on grandiosity in the assessment of narcissism. In contrast, clinical theory struggles with a proliferation of labels describing these broad phenotypic variations. We conclude that the construct of pathological narcissism is at a crossroads and provide recommendations for diagnostic assessment, clinical conceptualization, and future research that could lead to a more integrated understanding of narcissistic personality and narcissistic personality pathology.

We review the literature on pathological narcissism and narcissistic personality disorder (NPD) and describe a significant criterion problem related to four inconsistencies in phenotypic descriptions and taxonomic models across clinical theory, research, and practice; psychiatric diagnosis; and social/personality psychology. This impedes scientific synthesis, weakens narcissism's nomological net, and contributes to a discrepancy between low prevalence rates of NPD and higher rates of practitioner-diagnosed pathological narcissism, along with an enormous clinical literature on narcissistic disturbances. Criterion issues must be resolved, including clarification of the nature of normal and pathological narcissism, incorporation of the two broad phenotypic themes of narcissistic grandiosity and narcissistic vulnerability into revised diagnostic criteria and assessment instruments, elimination of references to overt and covert narcissism that reify these modes of expression as distinct narcissistic types, and determination of the appropriate structure for pathological narcissism. Implications for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the science of personality disorders are presented.