12

Narcissistic and Histrionic Personality Disorders

Sindes Dawood, Leila Z. Wu, Chloe F. Bliton, AND Aaron L. Pincus

The personality disorders with the most research (Antisocial, Borderline) were grouped in Cluster B (dramatic, erratic) of the Diagnostic and Statistical Manual of Mental Disorders 3rd Edition (DSM-III; American Psychological Association, 1980) and its subsequent revisions. Narcissistic Personality Disorder (NPD) and Histrionic Personality Disorder (HPD), the remaining DSM Cluster B disorders, are both covered in this chapter. This pairing is an interesting one because of their historical similarities yet discrepant contemporary trajectories. NPD and HPD are among the oldest characterizations of personality pathology in psychiatry and psychology. Both have roots in early psychoanalytic theory (Freud, 1914, 1931; Reich, 1949) and remain prominent in contemporary psychodynamic theory and practice (Fonagy & Luyten, 2012, Lingiardi & McWilliams, 2015; McWilliams, 2011; Ronningstam, 2011a). In parallel, narcissistic and histrionic personalities were also incorporated into descriptive psychiatry (Decker, 2013; Schneider, 1923).

Since their appearance in the DSM-III however, the trajectory of NPD and HPD as basic forms of personality pathology have diverged. Clinical interest in understanding, assessing, and treating narcissistic patients remains strong and is growing (Hinrichs, 2016; Ogrodniczuk, 2013; Pincus, Cain, & Wright, 2014). Consistent with clinical interests, research on narcissism in all its forms is at an all-time high (Miller, Lynam, Hyatt, & Campbell, 2017; Pincus, Roche, & Good, 2015). In stark contrast, clinical interest in understanding, assessing, and treating histrionic patients has waned and empirical research focusing on histrionic personality pathology is relatively scant and arrested (Bornstein, Denckla, & Chung, 2015). Some even conclude that “The concept of HPD is dead” (Blashfield, Reynolds, & Stennett, 2012, p. 623; see also Bakkevig & Karterud, 2010). For HPD to remain relevant in contemporary personality disorder classification these circumstances must change.

More generally, personality disorder classification and diagnosis are in flux. The DSM-5 (American Psychiatric Association, 2013) contains two distinct systems for personality disorder diagnosis. The categorical personality disorder model found in Section II reprints the DSM-IV-TR (American Psychiatric Association, 2000) diagnostic criteria without change. This is unfortunate, as it reflects none of the research on personality disorders conducted in the years since DSM-IV’s original publication in 1994. The hybrid categorical/dimensional Alternative Model for Personality Disorders (AMPD; Skodol, 2012) was developed by the DSM-5 Personality and Personality Disorders Workgroup as part of the manual’s revision process. The AMPD was approved by the DSM-5 Task Force, but the Board of Trustees of the American Psychiatric Association chose to place it in Section III for emerging measures and models as an “official” alternative that can receive the DSM-5 code of Other Specified Personality Disorder [301.89] (Zachar, Krueger, & Kendler, 2016). Similar disagreements emerged during the revision of personality disorder diagnosis for the International Classification of Diseases 11th edition (ICD-11) as it evolved toward a model like the DSM-5 AMPD (Herpertz et al., 2017; Hopwood et al., 2018; Hopwood et al., 2019; Krueger, 2016; Tyrer et al., 2011, 2014).

Beyond the DSM-5 and ICD-11 diagnostic systems, many forms of personality pathology, such as psychopathy (Hare & Neumann, 2008) and pathological narcissism (Pincus & Lukowitsky, 2010) are also conceptualized and assessed with purely dimensional and multidimensional models or by profiles of extreme scores on general personality trait dimensions such as the Five-Factor Model (Widiger & Costa, 2013). In this chapter, we review NPD and HPD from these three perspectives: Categorical (DSM-5 Section II), Hybrid Categorical/Dimensional (DSM-5 Section III), and Dimensional (pathological and normal traits).

Narcissistic Personality Pathology

This section presents three conceptualizations of narcissistic personality pathology. First, we review the DSM-5 Section II categorical NPD diagnosis including its prevalence, stability, comorbidity, and empirical research base. Then we review DSM-5 Section III AMPD hybrid NPD diagnosis, including a description of the model and a review of its clinical applications to NPD. Finally, we review a pair of dimensional approaches to pathological narcissism, including the grandiosity/vulnerability model and the Five-Factor Model.

Categorical NPD (DSM-5 Section II)

NPD was first introduced in DSM-III reflecting the body of literature on narcissism prior to 1980. DSM-III criteria mainly reflected grandiose attitudes and behaviors (e.g., grandiose sense of self-importance) with some attention to self and emotion regulation (e.g., idealized and devalued views of self and others) and deflation following criticism (Pincus et al., 2015). In an effort to improve reliability and reduce the overlap among DSM PD criteria sets, the NPD diagnosis from DSM-III to DSM-5 underwent notable changes: adding a number of criteria explicitly emphasizing grandiosity (e.g., arrogant, haughty behaviors and/or attitudes; frequently infers others are envious of him/her) and eliminating criteria and text describing dysregulation and vulnerability (e.g., shameful reactivity or humiliation in response to narcissistic injury, alternating states of idealization and devaluation) (Gunderson, Ronningstam, & Smith, 1995).

As the DSM-5 Section II personality disorder criteria remain unchanged from DSM-IV-TR, the current diagnostic criteria continue to reflect chronic expressions of excessive grandiosity and a somewhat narrow conceptualization of NPD as pathological grandiosity (Pincus, 2011). DSM-5 Section II describes NPD as a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy, beginning by early adulthood and present in a variety of contexts, operationalized as nine diagnostic criteria paraphrased here: (i) an inflated sense of self-worth; (ii) preoccupation with fantasies of unlimited influence, achievement, intelligence, attractiveness, or romance; (iii) belief that one is distinctive and elite and should only associate with others of similar stature; (iv) excessive needs for respect, appreciation, and praise; (v) sense of privilege; (vi) willingness to take advantage of others for personal gain; (vii) lack of compassion; (viii) jealousy of others; and (ix) exhibition of conceited behaviors and attitudes. A patient must meet clinical threshold for a minimum of five of these criteria to be diagnosed with NPD. Thus, the DSM-5 Section II diagnosis of NPD reflects chronic expressions of excessive grandiosity. Consistent with this, a confirmatory factor analysis of these NPD criteria supported a one-factor solution (Miller, Hoffman, Campbell, & Pilkonis, 2008). Self-esteem vulnerability and emotional dysregulation are only mentioned in the “Associated Features Supporting Diagnosis” section where clinicians are also cautioned that patients with NPD may not outwardly exhibit vulnerable characteristics. DSM-5 Section II diagnostic criteria are mainly limited to observable presentations of narcissism and omit the underlying features that maintain and unify heterogeneous clinical presentations of narcissism (Caligor, Levy, & Yeomans, 2015).

Prevalence

Prevalence rates of NPD in the general population range from 0 percent to 5.3 percent (Ekselius, Tillfors, Furmark, & Fredrikson, 2001; Mattia & Zimmerman, 2001; Torgersen, Kringlen, & Cramer, 2001). A nationally representative epidemiological study found that the lifetime prevalence (i.e., cumulative assessment across all time points) of NPD is 6.2 percent (Stinson et al., 2008). Overall, NPD exhibits the lowest prevalence rate of any DSM personality disorder; however, this is inconsistent with the frequency of patients with narcissistic personality pathology reported in clinical practice (Cain, Pincus, & Ansell, 2008). Prevalence estimates among clinical samples range from 1.3 percent to 22 percent (e.g., Grilo et al., 1998; Zimmerman, Rothschild, & Chelminski, 2005). Among personality disorders, NPD typically has among the lowest correlation between clinical interviews and self-report ratings (Oltmanns & Turkheimer, 2006), possibly due to a lack of insight into how behavior is perceived by others (Carlson & Oltmanns, 2015) or a disregard for the negative impact of their behavior on others (Carlson, 2013). This might particularly impact the accuracy of typical population-based epidemiological assessments, as individuals with NPD may lack the insight or willingness to disclose narcissistic attitudes or difficulties (or even participate in such assessments).

Stability

Examination of the temporal stability of NPD varies depending on whether clinical interview or self-report is employed. Ronningstam, Gunderson, and Lyons (1995) employed the Diagnostic Interview for Narcissism (DIN; Gunderson, Ronningstam, & Bodkin, 1990) on 20 patients diagnosed with NPD over a three-year period. They found only modest diagnostic stability, with only 33 percent of the patients continuing to meet the DIN criteria for NPD at follow-up. The three-year stability of DSM-III-R diagnoses (50 percent) and DSM-IV diagnoses (46 percent) were slightly higher. Lenzenweger, Johnson, and Willett (2004) conducted individual growth curve analyses of interviewer-rated PD features over a four-year period in a sample of 250 participants. Results revealed significant variability in PD features, including NPD features, over time. Nestadt and colleagues (2010) interviewed 294 participants on two occasions, 12 to 18 years apart and found that NPD had among the lowest temporal stability levels (ICC = 0.10), and NPD traits at baseline did not significantly predict those same traits at follow-up. Self-reported NPD symptoms yielded a higher level of stability. Ball, Rounsaville, Tennen, and Kranzler (2001) reported a one-year temporal stability coefficient of 0.42 for the self-reported DSM-III-R NPD features in a clinical sample of 182 substance abusing inpatients. Samuel and colleagues (2011) examined the two-year rank order and mean level stability of PDs using self-report and interview based assessments. They found the rank order stability for NPD was higher for self-report than for interview ratings, and the mean level decrease in symptoms over time was smaller for the self-report compared to the interview ratings. Supporting previous findings, Vater et al. (2014) found a two-year remission rate for NPD diagnoses of 52 percent. Even with self-report measures, the temporal stability of DSM Section II NPD diagnosis remains quite modest.

Comorbidity

Numerous studies indicate that NPD exhibits the highest rates of comorbidity with antisocial and histrionic personality disorders, and is also commonly comorbid with borderline and schizotypal personality disorders (Levy, Chauhan, Clarkin, Wasserman, & Reynoso, 2009; Widiger, 2011). NPD also co-occurs with symptom syndromes, specifically bipolar 1 disorder, anxiety disorders, substance abuse disorder, posttraumatic stress disorder, and major depression (Clemence, Perry, & Plakun, 2009; Simonsen & Simonsen, 2011; Stinson et al., 2008).

DSM-5 Section II NPD Research

Due in part to the low prevalence of NPD, substantive research employing even modest samples of patients diagnosed with NPD is extremely rare. Most of this work has focused on examining empathy deficits and self-esteem in NPD. The best research of this nature involves a well-diagnosed sample of NPD patients in Germany. The investigators (Ritter et al., 2011) used both self-report and experimental methods to assess empathy and found that, compared to controls and patients with borderline personality disorder, NPD patients exhibited deficits in emotional empathy (i.e., an observer’s emotional response to another person’s emotional state) but not cognitive empathy (i.e., the ability to take another person’s perspective and to represent others’ mental states). This distinction could explain the NPD patient’s tendency to successfully exploit others. In another study of these NPD patients (Schulze et al., 2013), the investigators used brain imaging techniques and found that, relative to controls, NPD patients had smaller gray matter volume in the left anterior insula. Importantly, gray matter volume in this area is positively correlated with self-reported emotional empathy. Supporting these conclusions, Nenadic and colleagues (2015) used voxel-based morphometry to identify structural issues in the brains of six patients diagnosed with NPD and found gray matter deficits in the right prefrontal and bilateral medial prefrontal regions. Frontal gray matter loss is associated with emotion dysregulation and deficits in coping behaviors. Complementary whole-brain analyses yielded smaller gray matter volume in fronto-paralimbic brain regions comprising the rostral and median cingulate cortex as well as dorsolateral and medial parts of the prefrontal cortex, all of which are implicated in empathic functioning (Schulze et al., 2013).

Consistent with these findings, another group of investigators (Marissen, Deen, & Franklen, 2012), using a small independent clinical sample of NPD patients, found that they generally performed worse on a facial emotion recognition task compared to controls. In addition to this general deficit in emotion recognition, patients with NPD showed a specific deficit for emotions representing fear and disgust.

Empirical studies of self-esteem in NPD patients demonstrate mixed results. Investigators have found evidence supporting that, despite the grandiosity emphasized in the diagnostic criteria, NPD patients have lower explicit self-esteem than controls (Vater, Ritter, et al., 2013; Vater, Schröder-Abé, et al., 2013). However, Marissen and colleagues (Marissen, Brouwer, Hiemstra, Deen, & Franken, 2016) found that implicit and explicit self-esteem did not differ between NPD patients and control groups (e.g., patients with other PDs and healthy controls). This makes sense considering NPD is commonly comorbid with anxiety disorders, mood disorders, and posttraumatic stress disorder.

Finally, current research efforts have focused on the role of shame in individuals with NPD. Notably, Ritter and colleagues (2014) investigated the association of NPD and explicit and implicit shame as measured by self-report and performance measures, respectively. A small group of patients diagnosed with NPD reported higher levels of explicit shame than patients diagnosed with borderline personality disorder and healthy controls. Implicit shame-self associations (versus anxiety-self associations) were significantly stronger in NPD patients than in the control groups. Findings support continuing investigation of shame related processes in NPD.

As NPD exhibits high rates of co-occurrence with personality, anxiety, mood, and substance use disorders, novel research has explored the mechanisms driving comorbidity. Eaton and colleagues (2017) used a nationally representative sample to model NPD’s transdiagnostic comorbidity structures through multivariate associations. Findings indicate that NPD is more strongly associated with a latent distress factor (versus a latent fear factor) within an internalizing–externalizing model. Furthermore, they concluded that NPD is composed of unique facets; however, it remains unclear whether shared variance and comorbidity represents a general factor of pathology overlapping with other disorders or an NPD-specific manifestation of unique symptoms. Hörz-Sagstetter and colleagues (2017) identified unique patterns of functioning among patients diagnosed with comorbid NPD and borderline personality disorder and patients only diagnosed with borderline personality disorder suggesting that comorbid NPD may serve as a buffer against anxiety and other Axis I disorders and reduce number of hospitalizations. However, within the context of a BPD diagnosis, NPD may also increase the co-occurrence of severe personality pathology including paranoia, antisocial personality features, and distortions of reality. Taken together, NPD exhibits unique associations with other disorders, and the basis for, and impact of such relationships must be further investigated.

Research on treatment of NPD is limited to case studies. There are no published randomized clinical psychotherapy trials, naturalistic studies of psychotherapy, or empirical evaluations of community-based interventions for NPD (Dhawan, Kunik, Oldham, & Coverdale, 2010; Levy, Reynoso, Wasserman, & Clarkin, 2007). Thus, there are no empirically validated treatments for NPD; however, extensions of empirically validated treatments such as dialectical behavior therapy (Reed-Knight & Fischer, 2011) and transference focused psychotherapy (Stern, Diamond, & Yeomans, 2017), are being developed.

Hybrid Dimensional/Categorical NPD (DSM-5 Section III AMPD)

The American Psychiatric Association officially recognizes the AMPD as an Alternative Model that complements the DSM-5 Section II PD diagnoses and has practical relevance for clinicians. Diagnosis with the AMPD requires fulfilling seven criteria for personality disorder. The first two, Criteria A (level of personality functioning) and Criteria B (maladaptive personality traits) are the most innovative. Criteria A involves clinician-rated assessment of severity of disturbances in selffunctioning (identity and self-direction) and interpersonal functioning (empathy and intimacy), reflecting impairments in regulatory and relational processes common to all personality disorders. Severity itself is an important clinical dimension, having significant implications for treatment planning (e.g., Caligor et al., 2015; Hopwood, Malone, et al., 2011; Pincus, Dowgwillo, & Greenberg, 2016; Yeomans, Clarkin, & Kernberg, 2015). Criteria B involves clinician and/or self-rated assessment of pathological personality traits which are organized into five broad trait domains (Negative Affectivity, Detachment, Antagonism, Disinhibition, Psychoticism) composed of 25 specific trait facets, reflecting individual differences in the expression of core personality impairments. Criteria C through G cover issues of pervasiveness, stability, early emergence, and discrimination from other mental disorders, effects of substances, and developmental stage or sociocultural environment. See the DSM-5 website for full descriptions and available assessment instruments.

What makes the AMPD a hybrid model is that it permits the diagnosis of six specific personality disorders (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal). For each personality disorder, specific criteria are provided for dimensional ratings of severity of personality impairments and specific elevations on maladaptive trait dimensions are specified. Maladaptive personality patterns not covered by these six criterion sets (e.g., personality disorders such as paranoid, schizoid, histrionic, and dependent) are diagnosed as Personality Disorder – Trait Specified (PD-TS). In a PD-TS diagnosis, Criterion A threshold is met and the specific clinically significant pathological trait elevations are stated in lieu of an overarching category (e.g., PD-TS with suspiciousness, restricted affectivity, and hostility may support the diagnosis of “paranoid personality disorder”). The Trait Specified diagnosis alleviates the problem of the highly common and ambiguous DSM-IV “Personality Disorder Not Otherwise Specified” diagnosis (Verheul, 2005) by providing a more clinically useful description of patients that do not fit well into the available categories. Also, categorical diagnoses can be augmented by additional notable trait elevations when indicated.

NPD in the DSM-5 AMPD

The DSM-5 AMPD diagnostic criteria for NPD are paraphrased in Table 12.1. These criteria improve upon the overly narrow DSM-5 Section II NPD diagnosis by including criteria for self and interpersonal impairments (Criterion A) and explicitly specifying that grandiosity may be overt or covert (see also Skodol, Morey, Bender, & Oldham, 2015). This provides the clinician with diagnostic criteria that exhibit greater fidelity with the varied presentations of pathological narcissism seen in clinical practice (Kealy & Rasmussen, 2012; McWilliams, 2011; Pincus et al., 2014). Although there are not yet empirical studies employing samples of patients diagnosed with DSM-5 AMPD personality disorders, it is notable that NPD is commonly discussed in the emerging literature detailing clinical applications of the AMPD. In fact, nearly all recent articles included at least one case of NPD (Bach, Markon, Simonsen, & Krueger, 2015; Schmeck, Schlüter-Müller, Foelsch, & Doering, 2013; Waugh et al., 2017); and four articles focused specifically on issues related to the diagnosis of AMPD NPD (Caligor et al., 2015; Morey & Stagner, 2012; Pincus et al., 2016; Skodol et al., 2015).

Table 12.1Paraphrased criteria for narcissistic personality disorder in the DSM-5 alternative model of personality disorders (Section III)

A.	Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
	1. Identity: Excessive reliance on others for self-concept and self-regard; self-evaluation is excessively exaggerated or devalued, or vacillating between extremes; affective instability mirrors fluctuations in self-regard.
	2. Self-direction: Aims based on gaining approval from others; perfectionistic achievement standards in order to see self as superior or excessively lax achievement standards based on a sense of privilege; often lacks insight regarding reasons for their behavior.
	3. Empathy: Impaired ability to notice or relate to the feelings and needs of others; overly focused on reactions of others, but only as it relates to self; disproportionately magnifies or minimizes own impact on others.
	4. Intimacy: Relationships largely self-serving and serve to promote self-regard; reciprocal functioning limited by lack of authentic curiosity in and concern for others’ experiences and excessive needs for status, victory, and admiration from others.
B.	Elevations on the following pathological personality traits:
	1. Grandiosity (a facet of Antagonism): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others.
	2. Attention seeking (a facet of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking

Research findings and clinical practitioners agree that the core feature of NPD is pathological grandiosity (Ackerman, Hands, Donnellan, Hopwood, & Witt, 2017; Pincus & Lukowitsky, 2010). The DSM-5 Section II NPD diagnosis and the DSM-5 AMPD NPD diagnosis also converge on this. However, the former criteria set is mainly limited to a narrow group of generally overt grandiose behaviors that result in low diagnostic prevalence (Pincus et al., 2015) and failure to capture actual clinical presentations of treatment seeking narcissistic patients (Caligor et al., 2015; Pincus et al., 2014; Skodol et al., 2015). In contrast, the AMPD Criteria A (regulatory and relational processes) and B (maladaptive traits) allow clinicians to accurately diagnose NPD in a wider range of cases, reducing false negatives and improving treatment recommendations. Meeting threshold for DSM-5 AMPD NPD Criteria A in combination with elevated grandiosity (and possibly attention-seeking) conceptualized as maladaptive traits (Criteria B) can capture a wider range of grandiose clinical presentations at varying levels of severity. Narcissistic grandiosity may be chronic but covert, chronic and overt, or oscillating with vulnerable self-states (Pincus et al., 2016).

In addition to recognizing the variations in expressions of grandiosity, three suggestions for revising the diagnosis of NPD to “re-incorporate” features of narcissistic vulnerability have appeared in the literature. One suggestion is to revise the DSM criteria to include features reflecting narcissistic vulnerability (e.g., Ronningstam, 2009). An alternative proposal is to consider narcissistic vulnerability as a specifier for NPD diagnoses (e.g., NPD with vulnerable features) similar to specifiers used for other diagnoses (Miller, Gentile, Wilson, & Campbell, 2013). A third alternative is to consider pathological narcissism a facet of general personality pathology, representing a core feature of all PDs rather than a specific personality disorder diagnosis (Morey, 2005; Morey & Stagner, 2012). However, this suggestion removes a very useful clinical diagnosis (Ronningstam, 2011b) and previously elicited significant negative reaction by the clinical community when the initial DSM-5 PD proposal suggested deleting NPD from the nosology (Skodol, 2012).

We agree with Skodol and colleagues (2015) that the DSM-5 AMPD NPD diagnosis appears to be a viable approach that is worthy of further study and refinement. Possible revisions to the DSM-5 AMPD NPD diagnosis to better account for narcissistic vulnerability could include expanding Criterion B beyond antagonism to include the facets of anhedonia or depressivity or the domain of negative affectivity. These could be required for diagnosis or they could be used to define a vulnerable specifier. Of course, such elevations would need to be carefully considered and distinguished from other possible comorbid diagnoses associated with negative affectivity.

Dimensional Approaches to Pathological Narcissism

In this section, we review two popular dimensional conceptualizations of pathological narcissism, the Grandiosity/Vulnerability model and its research base, and the Five-Factor Model trait perspective.

Narcissistic Grandiosity and Vulnerability Model

Narcissism can be defined as an individual’s tendency to use a variety of self-regulation, affect-regulation, and interpersonal processes to maintain a positive – and possibly inflated – self-image. Thus, it is necessarily a complex personality construct involving (a) needs for recognition and admiration, (b) motivations to overtly and covertly seek out self-enhancement experiences from the social environment, (c) strategies to satisfy these needs and motives, and (d) abilities to manage self-enhancement failures and social disappointments (Morf, 2006; Morf, Horvath, & Torchetti, 2011; Morf & Rhodewalt, 2001).

Recent efforts to synthesize the corpus of description, theory, and research on pathological narcissism across the disciplines generated a contemporary model (Figure 12.1) that conceptualizes pathological narcissism as a combination of maladaptive self-enhancement motivation (Grandiosity) and impaired self, emotion, and interpersonal regulation (Vulnerability) in response to self-enhancement failures and lack of recognition and admiration from others (Cain et al., 2008; Pincus & Lukowitsky, 2010; Pincus et al., 2015). Put another way, narcissistic individuals have notable difficulties transforming narcissistic needs (recognition and admiration) and impulses (self-enhancement motivation) into mature and socially appropriate ambitions and conduct (Kohut, 1977; Stone, 1998), and this heightens their sensitivity to the daily ups and downs of life and relationships (e.g., Besser & Priel, 2010; Besser, Zeigler-Hill, Weinberg, & Pincus, 2016; Ziegler-Hill & Besser, 2013). Such narcissistic vulnerability is reflected in experiences of anger, envy, aggression, helplessness, emptiness, low self-esteem, shame, avoidance of interpersonal relationships, and even suicidality (Kohut & Wolf, 1978; Krizan & Johar, 2012; Roche, Pincus, Lukowitsky, Ménard, & Conroy, 2013; Ronningstam, 2005).

Figure 12.1

The hierarchical structure of pathological narcissism.

By permission from Pincus, A. L., & Lukowitsky, M. R. (2010). Pathological narcissism and narcissistic personality disorder. Annual Review of Clinical Psychology, 6, p. 431.

As seen in Figure 12.1, narcissistic grandiosity and vulnerability together make up the higher order construct of pathological narcissism and are moderately inter-correlated (Wright, Lukowitsky, Pincus, & Conroy, 2010; Zeigler-Hill, Enjaian, & Essa, 2013). Expressions of narcissistic grandiosity and vulnerability may be chronic with each suppressing the other, or they may oscillate over time within the same person (Gore & Widiger, 2016; Hyatt et al., 2018; Pincus et al., 2016; Pincus & Wright, in press). Nevertheless, they exhibit convergent and divergent patterns of relationships across personality traits, internalizing and externalizing problems, self-esteem, self-conscious emotions, core affect, interpersonal functioning, and psychotherapy (Dowgwillo, Dawood, & Pincus, 2016; Pincus & Roche, 2011).

Research on Grandiosity and Vulnerability

Narcissistic grandiosity and vulnerability demonstrate distinct and substantially meaningful patterns of correlations across impulsive and perfectionistic traits, and omnibus models of general personality traits. Grandiosity is positively related to positive urgency and sensation seeking, while vulnerability is positively related to both positive and negative urgency components of impulsivity (Miller et al., 2010). Both grandiosity and vulnerability are positively associated with socially prescribed perfectionism and perfectionistic self-promotion; however, grandiosity is also associated with other-oriented perfectionism while vulnerability is associated with nondisclosure of imperfection (Smith et al., 2016). In terms of Five-Factor Model personality traits, grandiosity is negatively correlated with neuroticism and agreeableness, and positively related to extraversion; vulnerability is similarly negatively correlated with agreeableness but is positively related to neuroticism and negative correlated with extraversion (Miller et al., 2010). Similar patterns are found in relation to the HEXACO personality model with the notable addition that both grandiosity and vulnerability are negatively related to honesty-humility (Bresin & Gordon, 2011).

Narcissistic grandiosity and vulnerability exhibit distinct and meaningful patterns of associations with internalizing problems and symptoms in both normal and clinical samples. This has been most extensively studied with depressive symptoms (Dawood & Pincus, 2018a; Ellison, Levy, Cain, Ansell, & Pincus, 2013; Erkoreka & Navarro, 2017; Kealy, Tsai, & Ogrodniczuk, 2012; Marčinko et al., 2014; Miller et al., 2010; Tritt, Ryder, Ring, & Pincus, 2010). In addition, narcissistic grandiosity and vulnerability are associated with suicide attempts and borderline personality disorder symptoms (Miller et al., 2010; Pincus et al., 2009), suicidal ideation (Jaksic, Marcinko, Hanzek, Rebernjak, & Ogrodniczuk, 2017), and non-suicidal self-injury (Dawood, Schroeder, Donnellan, & Pincus, 2018).

Narcissistic grandiosity and vulnerability also exhibit distinct and meaningful patterns of associations with externalizing problems and symptoms in both normal and clinical samples. Numerous laboratory-based and correlational studies (Lobbestael, Baumeister, Feibig, & Eckel, 2014; Reidy, Foster, & Zeichner, 2010; Widman & McNulty, 2010) show that grandiosity is positively associated with all forms of aggression (e.g., reactive, proactive, unprovoked, sexual), as well as violent behavior and self-reported homicidal thoughts in psychotherapy inpatients and outpatients (Ellison et al., 2013; Goldberg et al., 2007). In contrast, vulnerability is associated with self-reported aggression, but not with aggressive behavior assessed in the laboratory. Grandiosity is also associated with increased criminal behavior and gambling (e.g., Miller et al., 2010), as well as alcohol and drug use (e.g., Buelow & Brunell, 2014). Moreover, vulnerability interacted with self-reported childhood sexual abuse to predict overt and cyber stalking in men (Ménard & Pincus, 2012).

Narcissistic grandiosity and vulnerability exhibit distinct associations with self-esteem, self-conscious emotions, and core affect. Vulnerability is negatively related with self-esteem, whereas grandiosity is positively correlated with self-esteem (Maxwell, Donnellan, Hopwood, & Ackerman, 2011; Miller et al., 2010; Pincus et al., 2009). Zeigler-Hill and Besser (2013) found that vulnerability is uniquely associated with day-to-day fluctuations in feelings of self-worth. Vulnerability is positively associated with shame and hubris, negatively associated with authentic pride, and unrelated to guilt. In contrast, grandiosity is positively correlated with guilt and unrelated to pride and shame (Pincus, 2013). Different facets of pathological narcissism also predict the within-person severity, within-person vacillation, and within-person instability of shame experienced over time (Dawood & Pincus, 2018b). Vulnerability is positively correlated with negative affectivity and envy, and negatively correlated with positive affectivity, while grandiosity is only positively related to positive affectivity (Krizan & Johar, 2012). Finally, high levels of pathological narcissism predicted strong experimental effects for the implicit priming of self-importance (Fetterman & Robinson, 2010).

Narcissistic grandiosity and vulnerability are also associated with specific types of interpersonal problems. Grandiosity is associated with predominantly vindictive, domineering, and intrusive problematic behaviors (Ogrodniczuk, Piper, Joyce, Steinberg, & Duggal, 2009; Pincus et al., 2009). Similarly, vulnerability is associated with vindictive interpersonal problems but also shows positive associations with exploitable and avoidant problems (Pincus et al., 2009). Grandiosity and vulnerability also exhibit meaningful associations with interpersonal sensitivities, with grandiosity associated with sensitivity to others’ remoteness, antagonism, and control, and vulnerability associated with sensitivity to others’ remoteness, control, attention-seeking, and affection (Hopwood, Ansell, et al., 2011).

Narcissistic grandiosity and vulnerability also show differential associations with the utilization of psychiatric treatment. For instance, Ellison and colleagues (2013) found that narcissistic grandiosity was negatively correlated with treatment utilization (telephone-based crisis services, partial hospitalizations, inpatient admissions, taking medications) and positively correlated with outpatient therapy no-shows. Narcissistic vulnerability was positively correlated with use of telephone-based crisis services, inpatient admissions, and outpatient therapy sessions attended and cancelled. Results indicating that narcissistic vulnerability is positively associated with treatment utilization support the view that narcissistic patients are likely to present for services when they are in a vulnerable self-state (Pincus et al., 2014).

NPD and the Five-Factor Model

Theorists and researchers have suggested that the Five-Factor Model (FFM; Costa & McCrae, 1992) of normal personality structure can be used to both conceptualize and assess NPD (e.g., Campbell & Miller, 2013). The lens through which narcissism can be understood from the perspective of the FFM is by expert opinions, as well as empirical research. For instance, mental health clinicians (Samuel & Widiger, 2004) and academic researchers (Lynam & Widiger, 2001) have independently reported a nearly identical FFM trait profile for a prototypical case of NPD. The traits considered to be most prototypical and descriptive of NPD include low levels of agreeableness (e.g., low modesty, altruism, trust, tender-mindedness), low and high levels of extraversion (e.g., low warmth, high excitement seeking, high assertiveness), and mixed levels of neuroticism (e.g., low self-consciousness, high angry hostility). Miller, Lynam, Siedor, Crowe, and Campbell (2018) extended this research by examining how lay people use the FFM to rate a narcissistic individual (based on their own conceptualization of narcissism) across different age, gender, and occupational categories. Results showed that, across all categories, lay people emphasize the same FFM traits as clinicians and researchers. Moreover, meta-analytic reviews on FFM and NPD (e.g., Samuel & Widiger, 2008; Saulsman & Page, 2004) also confirm low agreeableness and high extraversion as central traits of NPD.

Given that most FFM-based personality disorder research relies on questionnaires that assess normal range personality traits, researchers have begun to develop FFM inventories that explicitly assess traits descriptive of the DSM personality disorders (see Widiger, Lynam, Miller, & Oltmanns, 2012). Thus, the Five Factor Narcissism Inventory (FFNI; Glover, Miller, Lynam, Crego, & Widiger, 2012) was created to assess the general personality traits most relevant to NPD, narcissistic grandiosity, and narcissistic vulnerability from an FFM perspective. The facets of the FFNI were identified based on expert consensus ratings and empirical findings. They include FFNI neuroticism (Reactive Anger, Shame, Indifference, Need for Admiration), FFNI extraversion (Exhibitionism, Authoritativeness, Thrill Seeking), FFNI openness (Grandiose Fantasies), FFNI antagonism (Cynicism/Distrust, Manipulativeness, Exploitativeness, Entitlement, Lack of Empathy, Arrogance), and FFNI conscientiousness (Acclaim Seeking). Glover et al. (2012) described how grandiose and vulnerable dimensions could be scored using the FFNI scales. Studies have shown that the FFNI grandiose and vulnerable narcissism scales manifest good convergent and discriminant associations with existing measures of narcissism, Dark Triad personality traits, interpersonal traits, externalizing and internalizing behaviors and symptoms, and romantic and attachment styles (see Miller, Gentile, & Campbell, 2013; Miller, Gentile, et al., 2013).

Recently, Miller and colleagues (2016) identified three factors across two samples in their factor analyses of the 15 FFNI facets. The first factor, labeled interpersonal antagonism (i.e., low agreeableness), included the subscales of manipulativeness, entitlement, empathy, arrogance, distrust, reactive anger, and thrill seeking. The second factor, labeled neuroticism, comprised a need for admiration, shame, and low indifference (i.e., high self-consciousness). The third factor, labeled agentic extraversion, consisted of the subscales of grandiose fantasies, acclaim seeking, exhibitionism, and authoritativeness. They found that existing measures of NPD are correlated with all three FFNI dimensions. Moreover, measures of narcissistic grandiosity and vulnerability were strongly correlated with FFNI interpersonal antagonism, but differentially related to the other two FFNI factors. Measures of narcissistic grandiosity (but not vulnerability) were correlated with FFNI agentic extraversion, while measures of narcissistic vulnerability (but not grandiosity) were correlated with FFNI neuroticism.

Histrionic Personality Pathology

This section presents three conceptualizations of histrionic personality pathology. First, we review the DSM-5 Section II categorical HPD diagnosis including its prevalence, stability, comorbidity, and empirical research base. Then we review the DSM-5 Section III AMPD hybrid HPD diagnosis. Finally, we review a pair of dimensional approaches to histrionic pathology, including the dimensional assessment of histrionism and the Five-Factor Model.

Categorical HPD (DSM-5 Section II)

Prior to HPD’s official introduction to the DSM-III, “emotionally unstable personality” appeared in DSM-I, and some consider this diagnosis a precursor to the current HPD diagnosis (e.g., Smith & Lilienfeld, 2012). In 1968, “hysterical personality” appeared in DSM-II focusing on the criteria of clinging to others, impressionistic speech, and over-the-top displays of emotion. Histrionic personality disorder first officially appeared in the DSM-III with an emphasis on dramatic, seductive, and attention seeking behaviors, manipulative suicidal attempts and gestures, and irrational, angry outbursts. Given that DSM-III’s HPD criteria significantly overlapped with borderline personality disorder criteria, DSM-IV aimed at reducing the co-occurrence of the disorders and removed the criteria of angry outbursts and manipulative suicidal behaviors from the HPD diagnosis (Pfohl, 1991). After maneuvering criteria to reduce overlap with other personality disorders (see Bakkevig & Karterud, 2010), DSM-5 Section II describes HPD as a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts operationalized as eight diagnostic criteria paraphrased here: (i) the need to be the center of attention; (ii) inappropriate and sexually seductive behavior; (iii) highly changeable and superficial expressions of emotion; (iv) use of physical appearance to attract attention; (v) generalized and vague speech; (vi) dramatic, over-the-top expressions of emotion; (vii) suggestibility; and (viii) views relationships as closer and warmer than they really are. A patient must meet clinical threshold for a minimum of five of these criteria to be diagnosed with HPD.

Prevalence

Using DSM-III, DSM-III-R, and DSM-IV diagnostic criteria, prevalence rates for histrionic personality disorder vary from 0 percent to 3.2 percent in community samples and 1 percent to 6 percent in psychiatric samples (see Bakkevig & Karterud, 2010 for a review). More recent studies estimate roughly equivalent rates in community settings (0.2–2.9 percent) and higher rates in clinical settings ranging (10–15 percent) (Bornstein et al., 2015; Smith & Lilienfeld, 2012). Notably, studies using standardized interviews to assess for HPD find a prevalence estimate of 2–3 percent in the general population.

Stability

Samuel and colleagues (2011) investigated the stability of HPD as a categorical diagnosis. The Diagnostic Interview for DSM-IV Personality Disorders (Zanarini, Frankenburg, Sickel, & Yong, 1996) and Schedule for Nonadaptive and Adaptive Personality SNAP-2 (Clark, Simms, Wu, & Casillas, 2008) were administered to participants in the Collaborative Longitudinal Personality Disorders Study (CLPS) at baseline and after two years. Across the categorical diagnoses, HPD estimates decreased after two years. The rank order values for HPD stability as assessed by the SNAP-2 and DIPD-IV were 0.45 and 0.21, respectively.

Comorbidity

HPD shares a complex association with personality disorders due to diagnostic overlap. Numerous studies employing odds ratios analyses suggest that HPD is highly comorbid with all personality disorders (e.g., Lenzenweger, Lane, Loranger, Kessler, 2007; Trull, Jahng, Tomko, Wood, & Sher, 2010). Notably, comorbidity levels are highest for other Cluster B and dependent personality disorders (Bakkevig & Karterud, 2010). Due to the similarity in diagnostic criteria including attention seeking behaviors and manipulativeness, HPD commonly co-occurs with borderline personality disorder. Furthermore, HPD and NPD both describe a dysfunctional pattern of excessive attention-seeking leading to increased levels of comorbidity (Blagov & Westen, 2008; Smith & Lilienfeld, 2012). Similarly, HPD and antisocial personality disorder (ASPD) are both characterized by reckless, impulsive, and manipulative behaviors (Cale & Lilienfeld, 2002). Taken together, some theorists suggest that histrionism is a specific subtype of borderline personality disorder (Blavog & Westen, 2008; Westen & Heim, 2003) or NPD (Bakkevig and Karterud, 2010), or a gender biased, female manifestation of ASPD (Ford & Widiger, 1989). Finally, over-reliance on others and the need for approval drive the co-occurrence of HPD with dependent personality disorder (Bornstein et al., 2015).

HPD exhibits moderate to high comorbidity rates with dissociative disorders (Boon & Draijer, 1993), major depression (Dyck et al., 2001), dysthymia (Pepper et al., 1995), and anxiety disorders (Blashfield & Davis, 1993). The presence of HPD may impact the course and severity of other forms of psychopathology. For example, patients with comorbid bipolar disorder and HPD had significantly more suicide attempts than patients with bipolar disorder but not HPD (Garno, Goldberg, Ramirez & Ritzler, 2005).

HPD Research

Due in part to the low prevalence rate and high rates of co-occurrence with other personality disorders, research employing samples diagnosed with HPD is limited. However, the potential for gender bias in the HPD diagnosis is a pivotal issue receiving decent empirical attention (Bornstein et al., 2015). DSM-5 Section II notes that HPD may occur more frequently in females than in males. Historically, HPD has been considered as a feminine disorder with increased prevalence rates in women (Grant et al., 2004; Torgersen et al., 2001) as the HPD criteria closely align with physical appearance and seductive, suggestive behaviors. However, some feminist perspectives suggest that the inclusion of stereotypical feminine characteristics in the DSM diagnosis reflects negative attitudes and assumptions of traditionally feminine interaction styles (Gould, 2011). Clinicians seem to agree that women use seduction as a means of fulfilling their needs more than men (Stone, 1993). Theorists have postulated that HPD and ASPD share diagnostic overlap in the domains of impulsivity, manipulation, and behavioral disinhibition (Blagov, Fowler, & Lilienfeld, 2007; Cale & Lilienfeld, 2002). Empirical evidence suggests that co-occurring HPD and ASPD in men is often viewed as simply ASPD (Bornstein et al., 2015). This echoes a broader tendency to diagnose HPD more frequently in women and ASPD more frequently in men when presented with case examples depicting antisocial behavior for both genders (Ford & Widiger, 1989).

Culture may also play an important role in HPD diagnosis, but empirical evidence is lacking. Few studies have investigated the association between HPD diagnoses and culture (Makaremi, 1990). However, prevalence rates among different cultural groups suggest inequity (Mullins-Sweatt, Wingate, & Lengel, 2012). Lower rates of HPD have been found in Asian cultures possibly due to socialization practices and the disapproval of outwardly sexual behavior (Johnson, 1993). Conversely, HPD is more frequently diagnosed in Latino cultures where emotional expression is encouraged (Padilla, 1995). More research is needed to clarify the role of culture in HPD prevalence rates.

Hybrid Dimensional/Categorical HPD (DSM-5 Section III AMPD)

In the hybrid DSM-5 AMPD, HPD is not included as a categorical diagnosis due to lack of sufficient empirical research and waning clinical interest. However, clinicians can use Personality Disorder – Trait Specified (PD-TS) to note the presence of histrionic personality traits (Criteria B) combined with moderate or greater impairment in personality functioning (Criteria A). The AMPD Criteria B traits most consistent with descriptions of HPD are attention seeking, separation insecurity, manipulativeness, emotional lability, intimacy avoidance (low), and restricted affectivity (low). One significant limitation of the DSM-5 AMPD trait model is that it lacks coverage of maladaptive interpersonal warmth (Pincus, 2011; Wright et al., 2012). This is a core feature of both HPD and dependent personality disorder, both of which were not retained as categorical diagnoses in the AMPD. Thus, a PD-TS trait profile for HPD may be limited in the current version of the AMPD.

Dimensional Approaches to Histrionism

Excluding scales and interviews constructed to assess DSM HPD criteria, only one contemporary dimensional measure of histrionism, the Brief Histrionic Personality Scale, is currently available (BHPS; Ferguson & Negy, 2014). The BHPS includes two facets, seductiveness and attention-seeking, which are correlated with self-report measures of HPD and extraversion. However, we could find no additional research using the BHPS or alternative dimensional measures of histrionic personality.

HPD and the Five-Factor Model

As with NPD, theorists and researchers have suggested that the FFM of normal personality structure provides utility in conceptualizing and assessing HPD. In a meta-analysis conducted by Saulsman and Page (2004), HPD displayed a weighted effect size of 0.42 with the factor extraversion. These results were echoed in Samuel and Widiger’s (2008) meta-analysis which exhibited a weighted effect size of 0.33 with extraversion. Within clinical settings, private practitioners described HPD cases as high in the extraversion facets of gregariousness and excitement-seeking (Samuel & Widiger, 2004). The prototypical presentation of HPD includes high levels on all facets of extraversion (e.g., warmth, gregariousness, assertiveness, activity, excitement seeking, and positive emotions) and the facets feelings and actions (openness) and trust (agreeableness) paired with low levels of the facets self-consciousness (neuroticism) and deliberation (conscientiousness) (Gore, Tomiatti, & Widiger, 2011; Lynam & Widiger, 2001).

More recently, a Five-Factor Histrionic Inventory (FFHI; Tomiatti, Gore, Lynam, Miller, & Widiger, 2012) was developed to assess the general personality traits most relevant to HPD. The facets include FFHI neuroticism (rapidly shifting emotions, melodramatic-emotionality), FFHI extraversion (attention seeking, intimacy seeking, social butterfly, flirtatiousness, vanity), FFHI agreeableness (touchy feely suggestibility, impressionistic thinking), FFHI openness (romantic fantasies), and FFHI conscientiousness (disorderliness). Tomiatti and colleagues (2012) reported good psychometric qualities, adequate convergent validity for 11 out of the 13 FFHI scales, and incremental validity over their respective NEO-PI-R facet scales for 12 out of 13 scales in accounting for variance in responses to the PDQ-4 HPD scale. However, we could find no other research employing the FFHI to empirically examine questions pertaining to histrionic personality functioning.

Future Directions for NPD and HPD

Because the state of personality disorder classification and diagnosis is in significant flux, we chose to review three prominent conceptualizations of NPD and HPD that are currently employed in clinical and research contexts, rather than reifying a single perspective. In considering the categorical DSM-5 Section II, hybrid DSM-5 AMPD, and dimensional approaches, we find conceptualization of NPD is advancing in promising ways, whereas the future of HPD seems unclear and less promising.

A major concern regarding DSM-IV NPD (and thus DSM-5 Section II NPD) raised a decade ago was that the diagnostic criteria focused too narrowly on observable grandiosity and were not consistent with clinical conceptualizations of pathological narcissism and patterns of comorbidity that included experiences of emotional dysregulation, shame, depression, withdrawal, depletion, and suicidality (Cain et al., 2008; Pincus & Lukowitsky, 2010). With the obvious exception of DSM-5 Section II NPD, the two other conceptualizations reviewed here address this concern. The DSM-5 AMPD recognizes that grandiosity can be overt or covert, assesses vulnerability through Criteria A’s regulatory and relational impairments, and assesses grandiosity though Criteria B’s antagonistic trait elevations. Contemporary dimensional models are operationalized by measures like the FFNI and Pathological Narcissism Inventory (Pincus et al., 2009) that assess both narcissistic grandiosity and narcissistic vulnerability. As the field advances, particularly regarding research on temporal processes and mechanisms (e.g., Wright, 2014; Wright & Edershile, 2018; Wright et al., 2017), an emergent and comprehensive model of narcissistic personality pathology that integrates personality structure (i.e., traits) and personality dynamics (i.e., temporal processes and mechanisms) appears within reach (Hopwood, Zimmerman, Pincus, & Krueger, 2015).

HPD is one of the least studied personality disorders across disciplines (Blashfield & Intoccia, 2000), resulting in a meaningful but sparse body of literature. HPD is also a controversial diagnosis with regard to its convergent and discriminate validity, its contentious history with roots in hysteria, concerns about gender bias, and a lack of treatment approaches and outcomes (Bornstein et al., 2015; Bornstein & Malka, 2009; Morey, Alexander, & Boggs, 2005). For these reasons, HPD was deleted from the DSM-5 AMPD (Skodol, 2012) and research and clinical interest has continued to wane. Sociocultural factors such as more liberal attitudes and norms for personal and sexual expression may have an impact on conceptions of disorder severity or even the disorder itself. Before declaring that HPD is dead (Blashfield et al., 2012), we see two promising avenues for advancing conceptualization of HPD. First, the DSM-5 AMPD could develop Criteria A descriptors and a pathological trait profile for HPD. The latter is hampered somewhat by the lack of Criteria B traits reflecting maladaptive warmth.

A potentially more promising approach is to increase research using the FFHI. This measure’s profile of traits overcomes the current DSM-5 AMPD limitation, assessing a broad array of problematic traits related to extraversion and agreeableness. Overall, the FFHI appears to cover all the major elements of histrionic personality pathology and we encourage additional research using this measure. If nothing is done in the next decade, it is unlikely that HPD will continue as a clinical diagnosis outside of psychodynamic practice.

References

Ackerman, R. A., Hands, A. J., Donnellan, M. B., Hopwood, C. J., & Witt, E. A. (2017). Experts’ views regarding the conceptualization of narcissism. Journal of Personality Disorders, 31, 346–361.

American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, DC: American Psychiatric Association.

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision). Washington, DC: American Psychiatric Association.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bach, B., Markon, K., Simonsen, E., & Krueger, R. (2015) Clinical utility of the DSM-5 Alternative Model of Personality Disorders: Six cases from practice. Journal of Psychiatric Practice, 21, 1–23.

Bakkevig, J. F., & Karterud, S. (2010). Is the Diagnostic and Statistical Manual of Mental Disorders, histrionic personality disorder category a valid construct? Comprehensive Psychiatry, 51, 462–470.

Ball, S. A., Rounsaville, B. J., Tennen, H., & Kranzler, H. R. (2001). Reliability of personality disorder symptoms and personality traits in substance-dependent inpatients. Journal of Abnormal Psychology, 110, 341–352.

Besser, A., & Priel, B. (2010). Grandiose narcissism versus vulnerable narcissism in threatening situations: Emotional reactions to achievement failure and interpersonal rejection. Journal of Social and Clinical Psychology, 29, 874–902.

Besser, A., Zeigler-Hill, V., Weinberg, M., & Pincus, A. P. (2016). Do great expectations lead to great disappointments? Pathological narcissism and the evaluation of vacation experiences. Personality and Individual Differences, 89, 75–79.

Blagov, P. S., Fowler, K. A., & Lilienfeld, S. O. (2007). Histrionic personality disorder. In W. O’Donohue, K. A. Fowler, & S. O. Lilienfeld (Eds.), Personality Disorders: Toward the DSM-V (pp. 203–232). Thousand Oaks, CA: Sage.

Blagov, P. S., & Westen, D. (2008). Questioning the coherence of histrionic personality disorder: Borderline and hysterical personality subtypes in adults and adolescents. Journal of Nervous and Mental Disease, 196, 785–797.

Blashfield, R. K., & Davis, R. T. (1993). Dependent and histrionic personality disorders. In P. B. Sutker & H. E. Adams (Eds), Comprehensive Handbook of Psychopathology (pp. 395–409). New York: Plenum.

Blashfield, R. K., & Intoccia, V. (2000). Growth of the literature on the topic of personality disorders. American Journal of Psychiatry, 157, 472–473.

Blashfield, R. K., Reynolds, S. M., & Stennett, B. (2012). The death of histrionic personality disorder. In T. A. Widiger (Ed.), The Oxford Handbook of Personality Disorders (pp. 603–627). New York: Oxford University Press.

Boon, S., & Draijer, N. (1993). The differentiation of patients with MPD or DDNOS from patients with a cluster B personality disorder. Dissociation, 6, 126–135.

Bornstein, R. F., Denckla, C. A., & Chung, W. J. (2015). Dependent and histrionic personality disorders. In P. H. Blaney, R. F. Krueger, & T. Millon (Eds.), Oxford Textbook of Psychopathology (3rd ed., pp. 659–680). New York: Oxford University Press.

Bornstein, R. F., & Malka, I. L. (2009). Dependent and histrionic personality disorders. In P. H. Blaney, & T. Millon (Eds.), Oxford Textbook of Psychopathology (pp. 602–621). New York: Oxford University Press.

Bresin, K., & Gordon, K. H. (2011). Characterizing pathological narcissism in terms of the HEXACO model of personality. Journal of Psychopathology and Behavioral Assessment, 33, 228–235.

Buelow, M. T., & Brunell, A. B. (2014). Facets of narcissistic grandiosity predict involvement in health-risk behaviors. Personality and Individual Differences, 69, 193–198.

Cain, N. M., Pincus, A. L., & Ansell, E. B. (2008). Narcissism at the crossroads: Phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clinical Psychology Review, 28, 638–656.

Cale, E. M., & Lilienfeld, S. O. (2002). Sex differences in psychopathy and antisocial personality disorder: A review and integration. Clinical Psychology Review, 22, 1179–1207.

Caligor, E., Levy, K. N., & Yeomans, F. E. (2015). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172, 415–422.

Campbell, W. K., & Miller, J. D. (2013). Narcissistic Personality Disorder (NPD) and the Five-Factor Model: Delineating NPD, grandiose narcissism, and vulnerable narcissism. In T. A. Widiger & P. T Costa (Eds.), Personality Disorders and the Five-Factor Model of Personality (3rd ed., pp. 133–146). Washington, DC: APA.

Carlson, E. N. (2013). Honestly arrogant or simply misunderstood? Narcissists’ awareness of their narcissism. Self and Identity, 12, 259–277.

Carlson, E. N., & Oltmanns, T. F. (2015). The role of metaperception in personality disorders: Do people with personality problems know how others experience their personality? Journal of Personality Disorders, 29, 449–467.

Clark, L. A., Simms, L. J., Wu, K. D., & Casillas, A. (2008). Manual for the Schedule for Adaptive and Nonadaptive Personality (SNAP-2). Minneapolis, MN: University of Minnesota Press.

Clemence, A. J., Perry, J. C., & Plakun, E. M. (2009). Narcissistic and borderline personality disorders in a sample of treatment refractory patients. Psychiatric Annals, 39, 175–184.

Costa, P. T., & McCrae, R. R. (1992). Revised NEO Personality Inventory (NEO-PI-R) and NEO Five Factor Inventory (NEO-FFI) Professional Manual. Odessa, FL: Psychological Assessment Resources.

Dawood, S., & Pincus, A. L. (2018a). Pathological narcissism and the severity, variability, and instability of depressive symptoms. Personality Disorders: Theory, Research, and Treatment, 9, 144–154.

Dawood, S., & Pincus, A.L. (2018b). A prospective study of pathological narcissism and shame. Manuscript under review.

Dawood, S., Schroeder, H. S., Donnellan, M. B., & Pincus, A. L. (2018). Pathological narcissism and non-suicidal self-injury. Journal of Personality Disorders, 32, 87–108.

Decker, H. S. (2013). The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry. New York: Oxford University Press.

Dhawan, N., Kunik, M. E., Oldham, J., & Coverdale, J. (2010). Prevalence and treatment of narcissistic personality disorder in the community: A systematic review. Comprehensive Psychiatry, 51, 333–339.

Dowgwillo, E. A., Dawood, S., & Pincus, A. L. (2016). The dark side of narcissism. In V. Zeigler-Hill & D. Marcus (Eds.), The Dark Side of Personality (pp. 25–44). Washington, DC: American Psychological Association.

Dyck, I. R., Phillips, K. A., Warshaw, M. G., Dolan, R. T., Shea, M. T., Stout, R. L., … Keller, M. B. (2001). Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia. Journal of Personality Disorders, 15, 60–71.

Eaton, N. R., Rodriguez-Seijas, C., Krueger, R. F., Campbell, W. K., Grant, B. F., & Hasin, D. S. (2017). Narcissistic personality disorder and the structure of common mental disorders. Journal of Personality Disorders, 31, 449–461.

Ekselius, L., Tillfors, M., Furmark, T., & Fredrikson, M. (2001). Personality disorders in the general population: DSM-IV and ICD-10 defined prevalence as related to sociodemographic profile. Personality and Individual Differences, 30, 311–320.

Ellison, W. D., Levy, K. N., Cain, N. M., Ansell, E. B., & Pincus, A. L. (2013). The impact of pathological narcissism on psychotherapy utilization, initial symptom severity, and early-treatment symptom change: A naturalistic investigation. Journal of Personality Assessment, 95, 291–300.

Erkoreka, L., & Navarro, B. (2017). Vulnerable narcissism is associated with severity of depressive symptoms in dysthymic patients. Psychiatry Research, 257, 265–269.

Ferguson, C. J., & Negy, C. (2014). Development of a brief screening questionnaire for histrionic personality symptoms. Personality and Individual Differences, 66, 124–127.

Fetterman, A. K., & Robinson, M. D. (2010). Contingent self-importance among pathological narcissists: Evidence from an implicit task. Journal of Research in Personality, 44, 691–697.

Fonagy, P., & Luyten, P. (2012). Psychodynamic models of personality disorders. In T. A. Widiger (Ed.), The Oxford Handbook of Personality Disorders (pp. 345–371). New York: Oxford University Press.

Ford, M. R., & Widiger, T. A. (1989). Sex bias in the diagnosis of histrionic and antisocial personality disorders. Journal of Consulting and Clinical Psychology, 57, 301–305.

Freud, S. (1914). On narcissism. In J. Strachey (Ed. and Trans.), The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. XIV, pp. 66-102). London: Hogarth Press.

Freud, S. (1931). Libidinal types. In J. Strachey (Ed. and Trans.), The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. XXII, pp. 310–333). London: Hogarth Press.

Garno, J. L., Goldberg, J. F., Ramirez, P. M., & Ritzler, B. A. (2005). Bipolar disorder with comorbid cluster B personality disorder features: Impact on suicidality. Journal of Clinical Psychiatry, 66, 339–345.

Glover, N., Miller, J. D., Lynam, D. R., Crego, C., & Widiger, T. A. (2012). The five factor narcissism inventory: A five-factor measure of narcissistic personality traits. Journal of Personality Assessment, 94, 500–512.

Goldberg, B. R., Serper, M. R., Sheets, M., Beech, D., Dill, C., & Duffy, K. G. (2007). Predictors of aggression on the psychiatric inpatient service: Self-esteem, narcissism, and theory of mind deficits. Journal of Nervous and Mental Disease, 195, 436–442.

Gore, W. L., Tomiatti, M., & Widiger, T. A. (2011). The home for histrionism. Personality and Mental Health, 5, 57–72.

Gore, W. L., & Widiger, T. A. (2016). Fluctuation between grandiose and vulnerable narcissism. Personality Disorders: Theory, Research, and Treatment, 7, 363–371.

Gould, C. S. (2011). Why the histrionic personality disorder should not be in the DSM: A new taxonomic and moral analysis. International Journal of Feminist Approaches to Bioethics, 4(1), 26–40.

Grant, B. F., Hasin, D. S., Stinson, F. S., Dawson, D. A., Chou, S. P., Ruan, W., & Pickering, R. P. (2004). Prevalence, correlates, and disability of personality disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 65, 948–958.

Grilo, C. M., McGlashan, T. H., Quinlan, D. M., Walker, M. L., Greenfeld, D., & Edell, W. S. (1998). Frequency of personality disorders in two age cohorts of psychiatric inpatients. American Journal of Psychiatry, 155, 140–142.

Gunderson, J., Ronningstam, E., & Bodkin, A. (1990). The diagnostic interview for narcissistic patients. Archives of General Psychiatry, 47, 676–680.

Gunderson, J., Ronningstam, E., & Smith, L. E. (1995). Narcissistic personality disorder. In J. Livesley (Ed.), The DSM-IV Personality Disorder Diagnoses (pp. 201–212). New York: Guilford Press.

Hare, R. D., & Neumann, C. S. (2008). Psychopathy as a clinical and empirical construct. Annual Review of Clinical Psychology, 4, 217–246.

Herpertz, S. C., Huprich, S. K., Bohus, M., Chanen, A., Goodman, M., Mehlum, L., … Sharp, C. (2017). The challenge of transforming the diagnostic system of personality disorders. Journal of Personality Disorders, 31, 577–589.

Hinrichs, J. (2016). Inpatient therapeutic assessment with narcissistic personality disorder. Journal of Personality Assessment, 98, 111–123.

Hopwood, C. J., Ansell, E. A., Pincus, A. L., Wright, A. G. C., Lukowitsky, M. R., & Roche, M. J. (2011). The circumplex structure of interpersonal sensitivities. Journal of Personality, 79, 707–740.

Hopwood, C. J., Kotov, R., Krueger, R. F., Watson, D., Widiger, T. A., Althoff, R. R., … Zimmermann, J. (2018). The time has come for dimensional personality disorder diagnosis. Personality and Mental Health, 12, 82–86.

Hopwood, C. J., Krueger, R. F., Watson, D., Widiger, T. A., Althoff, R. R., Ansell, E. B., … Zimmermann, J. (2019). Commentary on “The challenge of transforming the diagnostic system for personality disorders.” Journal of Personality Disorders, online commentary: https://guilfordjournals.com/doi/abs/10.1521/pedi_2019_33_00

Hopwood, C. J., Malone, J. C., Ansell, E. B., Sanislow, C. A., Grilo, C. M., McGlashan, T. H., … Morey, L. C. (2011). Personality assessment in DSM-5: Empirical support for rating severity, style, and traits. Journal of Personality Disorders, 25, 305–320.

Hopwood, C. J., Zimmermann, J., Pincus, A. L., & Krueger, R. F. (2015). Connecting personality structure and dynamics: Towards a more evidence based and clinically useful diagnostic scheme. Journal of Personality Disorders, 29, 431–448.

Hörz-Sagstetter, S., Diamond, D., Clarkin, J. F., Levy, K. N., Rentrop, M., Fischer-Kern, M., … Doering, S. (2017). Clinical characteristics of comorbid narcissistic personality disorder in patients with borderline personality disorder. Journal of Personality Disorders, 32(4), 1–14.

Hyatt, C. S., Sleep, C. E., Lynam, D. R., Widiger, T. A., Campbell, W. K., & Miller, J. D. (2018). Ratings of affective and interpersonal tendencies differ for grandiose and vulnerable narcissism: A replication and extension of Gore & Widiger. Journal of Personality, 86(3), 422–434.

Jaksic, N., Marcinko, D., Hanzek, M. S., Rebernjak, B., & Ogrodniczuk, J. S. (2017). Experience of shame mediates the relationship between pathological narcissism and suicidal ideation in psychiatric outpatients. Journal of Clinical Psychology, 73, 1670–1681.

Johnson, F. A. (1993). Dependency and Japanese Socialization. New York: New York University Press.

Kealy, D., & Rasmussen, B. (2012). Veiled and vulnerable: The other side of grandiose narcissism. Clinical Social Work Journal, 40, 356–366.

Kealy, D., Tsai, M., & Ogrodniczuk, J. S. (2012). Depressive tendencies and pathological narcissism among psychiatric outpatients. Psychiatry Research, 196, 157–159.

Kohut, H. (1977). The Restoration of the Self. New York: International Universities Press.

Kohut, H., & Wolf, E. S. (1978). The disorders of the self and their treatment: An outline. International Journal of Psychoanalysis, 59, 413–425.

Krizan, Z., & Johar, O. (2012). Envy divides the two faces of narcissism. Journal of Personality, 80, 1415–1451.

Krueger, R. F. (2016). The future is now: Personality disorder and the ICD‐11. Personality and Mental Health, 10, 118–119.

Lenzenweger, M. F., Johnson, M. D., & Willett, J. (2004). Individual growth curve analysis illuminates stability and change in personality disorder features: The longitudinal study of personality disorders. Archives of General Psychiatry, 61, 1015–1024.

Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6), 553–564.

Levy, K. N., Chauhan, P., Clarkin, J. F., Wasserman, R. H., & Reynoso, J. S. (2009). Narcissistic pathology: Empirical approaches. Psychiatric Annals, 39(4), 203–213.

Levy, K. N., Reynoso, J. S., Wasserman, R. H., & Clarkin, J. F. (2007). Narcissistic personality disorder. In W. O’Donohue, K. A. Fowler, & S. O. Lilienfeld (Eds.), Personality Disorders: Toward the DSM-V (pp. 233–277). Thousand Oaks, CA: Sage.

Lingiardi, V., & McWilliams, N. (2015). The psychodynamic diagnostic manual–2nd edition (PDM-2). World Psychiatry, 14, 237–239.

Lobbestael, J., Baumeister, R. F., Feibig, T., & Eckel, L. A. (2014). The role of grandiose and vulnerable narcissism in self-reported and laboratory aggression and testosterone reactivity. Personality and Individual Differences, 69, 22–27.

Lynam, D. R., & Widiger, T. A. (2001). Using the five-factor model to represent the DSM-IV personality disorders: An expert consensus approach. Journal of Abnormal Psychology, 110, 401–412.

Makaremi, A. (1990). Histrionic disorder among Iranian high school and college students. Psychological Reports, 66(3), 835–838.

Marčinko, D., Jakšić, N., Ivezić, E., Skočić, M., Surányi, Z., Lončar, M., … Jakovljević, M. (2014). Pathological narcissism and depressive symptoms in psychiatric outpatients: Mediating role of dysfunctional attitudes. Journal of Clinical Psychology, 70, 341–352.

Marissen, M. A., Deen, M. L., & Franken, I. H. (2012). Disturbed emotion recognition in patients with narcissistic personality disorder. Psychiatry Research, 198, 269–273.

Marissen, M. A., Brouwer, M. E., Hiemstra, A. M., Deen, M. L., & Franken, I. H. (2016). A masked negative self-esteem? Implicit and explicit self-esteem in patients with Narcissistic Personality Disorder. Psychiatry Research, 242, 28–33.

Mattia, J., & Zimmerman, M. (2001). Epidemiology. In W. J. Livesley (Ed.), The Handbook of Personality Disorders (pp. 107–123). New York: Guilford Press.

Maxwell, K., Donnellan, M. B., Hopwood, C. J., & Ackerman, R. A. (2011). The two faces of Narcissus? An empirical comparison of the Narcissistic Personality Inventory and the Pathological Narcissism Inventory. Personality and Individual Differences, 50, 577–582.

McWilliams, N. (2011). Psychoanalytic Diagnosis (2nd ed.). New York: Guilford Press.

Ménard, K. S., & Pincus, A. L. (2012). Predicting overt and cyber stalking perpetration by male and female college students. Journal of Interpersonal Violence, 27, 2183–2207.

Miller, J. D., Dir, A., Gentile, B., Wilson, L., Pryor, L. R., & Campbell, W. K. (2010). Searching for a vulnerable dark triad: Comparing factor 2 psychopathy, vulnerable narcissism, and borderline personality disorder. Journal of Personality, 85, 1529–1564.

Miller, J. D., Gentile, B., & Campbell, W. K. (2013). A test of the construct validity of the Five-Factor Narcissism Inventory. Journal of Personality Assessment, 95, 377–387.

Miller, J. D., Gentile, B., Wilson, L., & Campbell, W. K. (2013). Grandiose and vulnerable narcissism and the DSM-5 pathological personality trait model. Journal of Personality Assessment, 95, 284–290.

Miller, J. D., Hoffman, B., Campbell, W. K., & Pilkonis, P. A. (2008). An examination of the factor structure of DSM-IV narcissistic personality disorder criteria: One or two factors? Comprehensive Psychiatry, 49, 141–145.

Miller, J. D., Lynam, D. R., Hyatt, C. S., & Campbell, W. K. (2017). Controversies in narcissism. Annual Review of Clinical Psychology, 13, 291–315.

Miller, J. D., Lynam, D. R., McCain, J. L., Few, L. R., Crego, C., Widiger, T. A., & Campbell, W. K. (2016). Thinking structurally about narcissism: An examination of the Five-Factor Narcissism Inventory and its components. Journal of Personality Disorders, 30, 1–18.

Miller, J. D., Lynam, D. R, Siedor, L., Crowe, M., Campbell, W. K. (2018). Consensual lay profiles of narcissism and their connection to the Five-Factor Narcissism Inventory. Psychological Assessment, 30, 10–18.

Morey, L. C. (2005). Personality pathology as pathological narcissism. In M. Maj, H. S. Akiskal, J. E. Mezzich, & A. Okasha (Eds.), Evidence and Experience in Psychiatry, Volume 8: Personality Disorders (pp. 328–331). New York: John Wiley.

Morey, L. C., Alexander, G. M., & Boggs, C. (2005). Gender and personality disorder. In J. Oldham, A. Skodol, & D. Bender (Eds.), Textbook of Personality Disorders (pp. 541-554). Washington, DC: American Psychiatric Press.

Morey, L. C., & Stagner, B. H. (2012). Narcissistic pathology as a core personality dysfunction: Comparing the DSM-IV and the DSM-5 proposal for narcissistic personality disorder. Journal of Clinical Psychology, 68, 908–921.

Morf, C. C. (2006). Personality reflected in a coherent idiosyncratic interplay of intra- and interpersonal self-regulatory processes. Journal of Personality, 76, 1527–1556.

Morf, C. C., Horvath, S., & Torchetti, T. (2011). Narcissistic self-enhancement: Tales of (successful?) self-portrayal. In M. D. Alicke & C. Sedikides (Eds.), Handbook of Self-Enhancement and Self-Protection (pp. 399–424). New York: Guilford Press.

Morf, C., & Rhodewalt, F. (2001). Unraveling the paradoxes of narcissism: A dynamic self-regulatory processing model. Psychological Inquiry, 12, 177–196.

Mullins-Sweatt, S. N., Wingate, L. R., & Lengel, G. J. (2012). Histrionic personality disorder: Diagnostic and treatment considerations. In P. K. Lundberg-Love, K. L. Nadal, & M. A. Paludi (Eds.) Women and Mental Disorders (pp. 57–73). Santa Barbara, CA: Praeger.

Nenadic, I., Güllmar, D., Dietzek, M., Langbein, K., Steinke, J., & Gaser, C. (2015). Brain structure in narcissistic personality disorder: A VBM and DTI pilot study. Psychiatry Research: Neuroimaging, 231, 184–186.

Nestadt, G., Di, C., Samuels, J. F., Bienvenu, O. J., Reti, I. M., Costa, P., … Bandeen-Roche, K. (2010). The stability of DSM personality disorders over twelve to eighteen years. Journal of Psychiatric Research, 44, 1–7.

Ogrodniczuk, J. S. (2013). Understanding and Treating Pathological Narcissism. Washington, DC: American Psychological Association.

Ogrodniczuk, J. S., Piper, W. E., Joyce, A. S, Steinberg, P. I., & Duggal, S. (2009). Interpersonal problems associated with narcissism among psychiatric outpatients. Journal of Psychiatric Research, 43, 837–842.

Oltmanns, T. F., & Turkheimer, E. (2006). Perceptions of self and others regarding pathological personality traits. In R. F. Krueger & J. L. Tackett (Eds.), Personality and Psychopathology (pp. 71–111). New York: Guilford Press.

Padilla, A. M. (1995). Hispanic Psychology: Critical Issues in Theory and Research. Newbury Pak, CA: Sage.

Pepper, C. M., Klein, D. N., Andersom, R. L., Riso, L. P., Ouimette, P. C., & Lizardi, H. (1995). DSM-llI-R Axis II comorbidity in dysthymia and major depression. American Journal of Psychiatry, 152, 239–247.

Pfohl, B. (1991). Histrionic personality disorder: A review of available data and recommendations for DSM-IV. Journal of Personality Disorders, 5, 150–166.

Pincus, A. L. (2011). Some comments on nomology, diagnostic process, and narcissistic personality disorder in the DSM-5 proposal for personality and personality disorders. Personality Disorders: Theory, Research, and Treatment, 2, 41–53.

Pincus, A. L. (2013). The Pathological Narcissism Inventory. In J. Ogrodniczuk (Ed.), Understanding and Treating Pathological Narcissism (pp. 93–110). Washington, DC: American Psychological Association.

Pincus, A. L., Ansell, E. B., Pimentel, C. A., Cain, N. M., Wright, A. G. C., & Levy, K. N. (2009). Initial construction and validation of the Pathological Narcissism Inventory. Psychological Assessment, 21, 365–379.

Pincus, A. L., Cain, N. M., & Wright, A. G. C. (2014). Narcissistic grandiosity and narcissistic vulnerability in psychotherapy. Personality Disorders: Theory, Research, and Treatment, 5, 439–443.

Pincus, A. L., Dowgwillo, E. A., & Greenberg, L. (2016). Three cases of narcissistic personality disorder through the lens of the DSM-5 alternative model for personality disorders. Practice Innovations, 1, 164–177.

Pincus, A. L., & Lukowitsky, M. R. (2010). Pathological narcissism and narcissistic personality disorder. Annual Review of Clinical Psychology, 6, 421–446.

Pincus, A. L., & Roche, M. J. (2011). Narcissistic grandiosity and narcissistic vulnerability. In W. K. Campbell & J. D. Miller (Eds.), Handbook of Narcissism and Narcissistic Personality Disorder (pp. 31–40). Hoboken, NJ: John Wiley.

Pincus, A. L., Roche, M. J., & Good, E. W. (2015). Narcissistic personality disorder and pathological narcissism. In P. H. Blaney, R. F. Krueger, & T. Millon (Eds.), Oxford Textbook of Psychopathology (3rd ed., pp. 791–813). New York: Oxford University Press.

Pincus, A. L., & Wright, A. G. C. (in press). Narcissism as the dynamics of grandiosity and vulnerability. In S. Doering, H.-P. Hartmann, & O. F. Kernberg (Eds.), Narzissmus: Grundlagen – Störungsbilder – Therapie (2nd ed.). Stuttgart: Schattauer Publishers.

Reed‐Knight, B., & Fischer, S. (2011). Treatment of narcissistic personality disorder symptoms in a dialectical behavior therapy framework. In J. D. Miller & W. K. Campbell (Eds.), The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments (pp. 466–475). Hoboken, NJ: John Wiley.

Reich, W. (1949). Character Analysis. New York: Farrar, Straus & Giroux.

Reidy, D. E., Foster, J. D., & Zeichner, A. (2010). Narcissism and unprovoked aggression. Aggressive Behavior, 36, 414–422.

Ritter, K., Dziobek, I., Preissler, S., Ruter, A., Vater, A., Fydrich T., … Roepke, S. (2011). Lack of empathy in patients with narcissistic personality disorder. Psychiatry Research, 187, 241–247.

Ritter, K., Vater, A., Rüsch, N., Schröder-Abé, M., Schütz, A., Fydrich, T., … Roepke, S. (2014). Shame in patients with narcissistic personality disorder. Psychiatry Research, 215(2), 429–437.

Roche, M. J., Pincus, A. L., Lukowitsky, M. R., Ménard, K. S., & Conroy, D. E. (2013). An integrative approach to the assessment of narcissism. Journal of Personality Assessment, 95, 237–248.

Ronningstam, E. (2005). Identifying and Understanding the Narcissistic Personality. New York: Oxford University Press.

Ronningstam, E. (2009). Narcissistic personality disorder: Facing DSM-V. Psychiatric Annuals, 39, 111–121.

Ronningstam, E. (2011a). Psychoanalytic theories on narcissism and narcissistic personality. In W. K. Campbell & J. D. Miller (Eds.), The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments (pp. 41–55). Hoboken, NJ: John Wiley.

Ronningstam, E. (2011b). Narcissistic personality disorder in DSM-V: In support of retaining a significant diagnosis. Journal of Personality Disorders, 25, 248–259.

Ronningstam, E., Gunderson, J., & Lyons, M. (1995). Changes in pathological narcissism. American Journal of Psychiatry, 152, 253–257.

Samuel, D. B., Hopwood, C. J., Ansell, E. B., Morey, L. C., Sanislow, C. A., Markowitz, J. C., … Grilo, C. M. (2011). Comparing the temporal stability of self-report and interview assessed personality disorder. Journal of Abnormal Psychology, 120, 670–680.

Samuel, D. B., & Widiger, T. A. (2004). Clinicians’ personality descriptions of prototypic personality disorders. Journal of Personality Disorders, 18, 286–308.

Samuel, D. B., & Widiger, T. A. (2008). A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: A facet level analysis. Clinical Psychology Review, 28, 1326–1342.

Saulsman, L. M., & Page, A. C. (2004). The five-factor model and personality disorder empirical literature: A meta-analytic review. Clinical Psychology Review, 23, 1055–1085.

Schmeck, K., Schlüter-Müller, S., Foelsch, P., & Doering, S. (2013). The role of identity in the DSM-5 classification of personality disorders. Child and Adolescent Psychiatry and Mental Health, 7, 1–11.

Schneider, K. (1923). Psychopathic Personalities. London: Cassell.

Schulze, L., Dziobek, I., Vater, A., Heekeren, H. R., Bajbouj, M., Renneberg, B., … Roepke, S. (2013). Gray matter abnormalities in patients with narcissistic personality disorder. Journal of Psychiatric Research, 47, 1363–1369.

Simonsen, S., & Simonsen, E. (2011). Comorbidity between narcissistic personality disorder and Axis I diagnoses. In W. K. Campbell & J. D. Miller (Eds.), The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments (pp. 239–247). Hoboken, NJ: John Wiley.

Skodol, A. E. (2012). Personality disorders in DSM-5. Annual Review of Clinical Psychology, 8, 317–344.

Skodol, A. E., Morey, L. C., Bender, D. S., & Oldham, J. M. (2015). The alternative DSM-5 model of personality disorders: A clinical application. American Journal of Psychiatry, 172, 606–613.

Smith, M. M., Sherry, S. B., Chen, S., Saklofske, D. H., Flett, G. L., & Hewitt, P. L. (2016). Perfectionism and narcissism: A meta-analytic review. Journal of Research in Personality, 64, 90–101.

Smith, S. F., & Lilienfeld, S. O. (2012). Histrionic personality disorder. In V. S. Ramachandran (Ed), Encyclopedia of Human Behavior (pp. 312–315). Amsterdam: Elsevier.

Stern, B. L., Diamond, D., & Yeomans, F. E. (2017). Transference-focused psychotherapy (TFP) for narcissistic personality: Engaging patients in the early treatment process. Psychoanalytic Psychology, 34, 381–396.

Stinson, F. S., Dawson, D. A., Goldstein, R. B., Chou, S. P., Huang, B., Smith, S. M., … Grant, B. F. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69, 1033–1045.

Stone, M. H. (1993). Abnormalities of Personality. New York: W. W. Norton.

Stone, M. H. (1998). Normal narcissism: An etiological and ethological perspective. In E. Ronningstam (Ed.), Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications (pp. 7–28). Washington, DC: American Psychiatric Publishing.

Tomiatti, M., Gore, W. L., Lynam, D. R., Miller, J. D., & Widiger, T. A. (2012). A five-factor measure of histrionic personality traits. In A. M. Columbus (Ed.), Advances in Psychology Research (Vol. 87, pp. 113–138). Hauppauge, NY: Nova Science Publishers.

Torgersen, S., Kringlen, E., & Cramer, V. (2001). The prevalence of personality disorders in a community sample. Archives of General Psychiatry, 58(6), 590–596.

Tritt, S. M., Ryder, A. G., Ring, A. J., & Pincus, A. L. (2010). Pathological narcissism and the depressive temperament. Journal of Affective Disorders, 122, 280–284.

Trull, T. J., Jahng, S., Tomko, R. L., Wood, P. K., & Sher, K. J. (2010). Revised NESARC personality disorder diagnoses: Gender, prevalence, and comorbidity with substance dependence disorders. Journal of Personality Disorders, 24(4), 412–426.

Tyrer, P., Crawford, M., Mulder, R., Blashfield, R., Farnam, A., Fossati, A., … Reed, G. M. (2011). The rationale for the reclassification of personality disorder in the 11th Revision of the International Classification of Diseases. Personality and Mental Health, 5, 246–259.

Tyrer, P., Crawford, M., Sanatinia, R., Tyrer, H., Cooper, S., Muller‐Pollard, C., … Weich, S. (2014). Preliminary studies of the ICD-11 classification of personality disorder in practice. Personality and Mental Health, 8, 254–263.

Vater, A., Ritter, K., Schröder-Abé, M., Schutz, A., Lammers, C. H., Bosson, J. K., & Roepke, S. (2013). When grandiosity and vulnerability collide: Implicit and explicit self-esteem in patients with narcissistic personality disorder. Journal of Behavior Therapy and Experimental Psychiatry, 44, 37–47.

Vater, A., Ritter, K., Strunz, S., Ronningstam, E. F., Renneberg, B., & Roepke, S. (2014). Stability of narcissistic personality disorder: Tracking categorical and dimensional rating systems over a two-year period. Personality Disorders: Theory, Research, and Treatment, 5, 305–313.

Vater, A., Schröder-Abé, M., Ritter, K., Renneberg, B., Schulze, L., Bosson, J. K., & Roepke, S. (2013). The Narcissistic Personality Inventory: A useful tool for assessing pathological narcissism? Evidence from patients with narcissistic personality disorder. Journal of Personality Assessment, 95, 301–308.

Verheul, R. (2005). Clinical utility of dimensional models for personality pathology. Journal of Personality Disorders, 19, 283–302.

Waugh, M., Hopwood, C. J., Krueger, R. F., Morey, L. C., Pincus, A. L., & Wright, A. G. C. (2017). Psychological assessment with the DSM-5 alternative model for personality disorders: Tradition and innovation. Professional Psychology: Research and Practice, 48, 79–89.

Westen, D., & Heim, A. K. (2003). Disturbances of self and identity in personality disorders. In M. R. Leary & J. P. Tangney (Eds.), Handbook of Self and Identity (pp. 643–666). New York: Guilford Press.

Widiger, T. A. (2011). The comorbidity of narcissistic personality disorder with other DSM-IV personality disorders. In W. K. Campbell & J. D. Miller (Eds.), Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatment (pp. 248–260). Hoboken, NJ: John Wiley.

Widiger, T. A., & Costa P. T. (Eds.) (2013). Personality Disorders and the Five-Factor Model of Personality (3rd ed.). Washington, DC: American Psychological Association.

Widiger, T. A., Lynam, D. R., Miller, J. D., & Oltmanns, T. F. (2012). Measures to assess maladaptive variants of the five-factor model. Journal of Personality, 94, 450–455.

Widman, L., & McNulty, J. K. (2010). Sexual narcissism and the perpetration of sexual aggression. Archives of Sexual Behavior, 39, 926–939.

Wright, A. G. C. (2014). Integrating trait-and process-based conceptualizations of pathological narcissism in the DSM-5 era. In A. Besser (Ed.), Handbook of Narcissism: Diverse Perspectives (pp. 153–174). Hauppauge, NY: Nova Science Publishers.

Wright, A. G. C., & Edershile, E. A. (2018). Issues resolved and unresolved in pathological narcissism. Current Opinion in Psychology, 21, 74–79.

Wright, A. G. C., Lukowitsky, M. R., Pincus, A. L., & Conroy, D.E. (2010). The higher-order factor structure and gender invariance of the pathological narcissism inventory. Assessment, 17, 467–483.

Wright, A. G. C., Pincus, A. L., Hopwood, C. J., Thomas, K. M., Markon, K. E., & Krueger, R. F. (2012). An interpersonal analysis of pathological personality traits in DSM-5. Assessment, 19, 263–275.

Wright, A. G. C., Stepp, S. D., Scott, L. N., Hallquist, M. N., Beeney, J. E., Lazarus, S. A., & Pilkonis, P. A. (2017). The effect of pathological narcissism on interpersonal and affective processes in social interactions. Journal of Abnormal Psychology, 126, 898–910.

Yeomans, F. E., Clarkin, J. F., & Kernberg, O. F. (2015). Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide. Arlington, VA: American Psychiatric Publishing.

Zachar, P., Krueger, R. F., & Kendler, K. S. (2016). Personality disorder in DSM-5: An oral history. Psychological Medicine, 46, 1–10.

Zanarini, M. C., Frankenburg, F. R., Sickel, A. E., & Yong, L. (1996). The Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Belmont, MA: McLean Hospital.

Zeigler-Hill, V., & Besser, A. (2013). A glimpse behind the mask: Facets of narcissism and feelings of self-worth. Journal of Personality Assessment, 95, 249–260

Zeigler-Hill, V., Enjaian, B., & Essa, L. (2013). The role of narcissistic personality features in sexual aggression. Journal of Social and Clinical Psychology, 32, 186–199.

Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of DSM-IV personality disorders in psychiatric outpatients. American Journal of Psychiatry, 162, 1911–1918.