12a
Brandon Weiss and W. Keith Campbell
The chapter on narcissistic personality disorder by Dawood, Wu, Bliton, and Pincus is well done and we agree with many of the authors’ key descriptions and arguments. At the same time, we believe there are important points to be made regarding their description of the disorder. The primary area of divergence from our perspective is their focus on narcissistic personality pathology, and narcissistic personality disorder (NPD) in particular, as a largely monolithic and unified construct. As a result, their description of the nomological network around NPD occurs with limited attention to potential distortions resulting from heterogeneity across scales that putatively measure NPD, overstatement of NPD’s vulnerable character, and insufficient concern for the influence of sampling on results. We address these three issues below and argue that a view of narcissism that is appropriately cautious about potential theoretical bias moors our craft closer to the headlands of truth and shelters us from the idiot wind of inflated scientific confidence.
NPD is Not a Narrow Construct
The first issue with the target authors’ chapter and the field more broadly relates to the multiple conceptualizations and corresponding assessments of NPD in the literature. Variability in the measurement of NPD makes any conclusions about the functioning of NPD misleading in the absence of earnest qualification. Since 2010, an average of 357 peer-reviewed articles have been published per year in which narcissism is discussed in the Abstract, amounting to a substantial change from previous years (e.g., 219 in 1990, and 173 in 2000) (Miller, Lynam, Hyatt, & Campbell, 2017). This growing interest has accompanied a corresponding increase in available measures that assess NPD. The majority of these measures are self-report inventories (e.g., Pathological Narcissism Inventory [PNI], Pincus et al., 2009; Personality Diagnostic Questionnaire-4, Hyler, 1994), while interview-based measures are common as well. Some of the clearest evidence of variability in the NPD construct across measures is contained in Samuel and Widiger’s (2008) correlational study which observed how NPD’s relations with Five-Factor Model (FFM) personality domains vary across the most widely used scales of NPD. Considerable variability can be seen across relations with all FFM domains, but particularly in relation to Neuroticism and Extraversion. Saulsman and Page (2004) demonstrated similar findings in a meta-analysis of correlations between NPD and personality. Across 18 samples in which at least seven different NPD measures were used, effect size estimates of relations between measures of NPD and Neuroticism, Extraversion, and Agreeableness, domains that are most related to NPD (e.g., Samuel & Widiger, 2008), were remarkably variable (Saulsman & Page, 2004, Table 2). For example, the standard deviations of sample effect size estimates approached .30 (in terms of units of Pearson r) for relations between NPD and Neuroticism, and .23 between NPD and Extraversion.
Of note, there are at least three contributors to the variability in these effect size estimates across measures of NPD. The first regards the potential effect of method variance on results. Across undergraduate, community, and psychiatric samples, weak to moderate convergence has been observed between self-report measures of NPD (e.g., PDQ-4) and interview-based measures (e.g., Hopwood et al., 2013). These results raise the importance of efforts to modify self-report measures, such that they bear greater convergence with interview measures; and examine where correlates with NPD diverge by measure type.
Second, differences in content in the wording of items on particular measures can produce outsized differences in the meaning and interpretation of items by respondents. Consider the difference between the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; APA, 2013) NPD criterion “… is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends” and the Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, Millon, & Davis, 1994) item designed to reflect it: i.e., “I don’t blame anyone who takes advantage of someone who allows it.” Although these items both describe attitudes towards exploitative behavior, the latter is notably passive whereas the former is active.
Third, measures vary in vulnerable content – that is, the proportion of vulnerable aspects of narcissism in the scale – may unduly bias results towards stronger relations between NPD and external correlates containing vulnerability (e.g., shame). Even fairly similar items may be sufficiently dissimilar to produce differences in interpretation by respondents. Note the difference between these two items within the Grandiose Fantasies subscale of the PNI: “I want to amount to something in the eyes of the world”; “I often fantasize about being admired and respected.” Although these items are treated as being representative of pathological grandiosity, the former item evokes a sense of unredeemed inadequacy, which is redolent of narcissistic vulnerability and may be more related to a need for validation than status or gain. Indeed, the grandiose dimension of the PNI, as well as other measures of pathological narcissism and NPD (e.g., PDQ-4, MCMI-III), contain negative emotionality/fragility (i.e., vulnerability) that differs from other measures (Miller, McCain, et al., 2014).
Differing Conceptualizations of NPD
The second issue in the target authors’ chapter involves the predetermining influence of the authors’ particular conceptualization of narcissism on conclusions about relations to external correlates. Differences between measures on the dimension of vulnerability can be linked to disagreement on conceptualizations of narcissism. The authors of the target chapter regard NPD as a self-regulatory disorder in which grandiose and vulnerable states oscillate in narcissistic individuals. Grandiose and vulnerable states are thought to stem from a common etiology, namely “intensely felt needs for validation and admiration,” which motivate the seeking out of self-enhancement experiences (grandiose) as well as “self-, emotion-, and behavioral dysregulation (vulnerable) when these needs go unfulfilled or ego threats arise” (p. 32; Pincus & Roche, 2011). This conceptualization is not without empirical support, with studies finding that grandiose narcissism is linked to greater reactivity of self-esteem to adverse interpersonal events (e.g., Rhodewalt, Madrian, & Cheney, 1998); that narcissistic antagonism may be associated with fluctuation between grandiosity and shame (Oltmanns & Widiger, 2018); and that grandiosity may covary with vulnerability at high levels of grandiosity (Jauk & Kaufman, 2018). However, when researchers who subscribe to a conceptualization of NPD involving oscillating grandiose and vulnerable states favor measures that include a greater proportion of items reflecting a need for validation, understanding, and vulnerability to negative emotionality, such as the PNI, this decision can bias the magnitude of relations with external correlates involving internalizing features (e.g., suicidality).
It would have been important for the target authors to acknowledge that many researchers do not regard extant empirical support for oscillating grandiose and vulnerable states to be adequately compelling. These researchers dispute that grandiose and vulnerable narcissistic states co-occur within individuals at a rate that would warrant considering them manifestations of the same underlying disorder. Their view is based on evidence suggesting that grandiose and vulnerable states do not meaningfully co-occur in the same individuals (Miller, Widiger, & Campbell, 2014); vulnerable states exhibited by grandiosely narcissistic individuals seem limited to reactive anger rather than internalizing-related emotions such as shame or distress (e.g., Hyatt et al., 2018); grandiose and vulnerable narcissism are associated with very different childhood histories (e.g., Miller et al., 2011); and grandiosity shows substantial within-person stability from day to day (e.g., Wright & Simms, 2016). The DSM largely reflects this conceptualization. Factor analyses of NPD symptoms indicate that the DSM-IV (and DSM-5) NPD criteria set is primarily consistent with grandiose narcissism (Fossati et al., 2005).
As a further example of lack of clarity on this issue, the empirical evidence is mixed with respect to where NPD is located within the structure of common mental disorders, with some findings suggesting that NPD may be characterized as an externalizing disorder (e.g., Kendler et al., 2011), others failing to find support for meaningful relations (e.g., Røysamb et al., 2011), and still others indicating that NPD is a distress disorder with stronger relations to internalizing, despite non-trivial relations to externalizing, and uniquely high disorder-specific variance that is not easily accounted for (Eaton et al., 2017). Unfortunately, the target authors included only the latter finding in their review.
Locating and Sampling NPD
The third issue with the target authors’ chapter and the literature more broadly involves how to address the substantial effect of sampling on researchers’ understanding of NPD. The target authors feature a preponderance of evidence from patient samples linking NPD to states of shame, lower explicit self-esteem, anxiety and mood disorders, emotion dysregulation, deficits in coping behaviors, and suicidality (e.g., Vater et al., 2013). However, it is important to consider the degree to which researchers’ reliance on small (i.e., n < 60) psychiatric samples containing disproportionally high concentrations of individuals with vulnerable features exerts a predetermining influence on the external correlates we investigate.
Traits that are generally thought to be most strongly and consensually related to NPD (e.g., grandiosity, domineering, manipulativeness) are often found to be higher in community samples than inpatient samples (e.g., Morf et al. 2017, Table 7), a phenomenon that may be driven in part by a higher likelihood of terminating psychotherapy among individuals with higher grandiosity (e.g., Ellison, Levy, Cain, Ansell, & Pincus, 2013). In contrast, research participants found in clinical samples tend to be substantially higher in traits that are relatively uncharacteristic of grandiose narcissism, such as depressiveness and anhedonia. Indeed, clinical samples tend to demonstrate high comorbidity with disorders that share a core of neuroticism (e.g., 53 percent for BPD [Vater et al., 2013]). One exception to this pattern is Stinson et al.’s (2008) large community sample that found NPD to be associated with internalizing disorders, though the measure used has not been adequately assessed. These selection concerns make interpreting research from clinical samples, especially inpatient samples (e.g., Vater et al. 2013), particularly challenging, as clinical samples of narcissism are likely to overrepresent vulnerable aspects and bias empirical results.
Conclusion
The target authors’ chapter provides a thorough description of NPD’s conceptualization across a variety of models and literatures. Nevertheless, we believe it is important for researchers to be appropriately attentive to sources of bias that can unnecessarily distort our assumed body of knowledge. A key source of bias is the field’s persistent disagreement about the structure and content of NPD and variability in its assessment. We support a more focused description of narcissism that places NPD as a disorder of antagonism in line with expert-based characterizations (e.g., Ackerman, Hands, Donnellan, Hopwood, & Witt, 2017) and FFM–NPD relations (e.g., Samuel & Widiger, 2008). The inclusion of specifiers would allow for the delineation of more grandiose and vulnerable forms of narcissism. Such a model would allow for individuals who exhibit co-occurring states of grandiose and vulnerable to be described with both specifiers. Nevertheless, the model we describe is a trait system, and thus would not easily describe a pattern of oscillating states. It is our view that data have not yet sufficiently demonstrated hypothesized self-regulatory psychodynamics in prototypical narcissism, particularly with respect to oscillation between grandiosity and vulnerability involving internalizing-related emotions such as shame and distress, although we regard this hypothesis worthy of continued examination. Longitudinal studies that examine fluctuations in grandiose and vulnerable states over temporally short increments are critical, as will be insights from physics-based systems models combined with trace data (e.g., Flack, 2012).
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