Pathological Narcissism and Depressive Symptoms in Psychiatric Outpatients: Mediating Role of Dysfunctional Attitudes

Measurement Invariance of the Pathological Narcissism Inventory and Multimethod Examination of Narcissistic Presentations in Community and Clinical Samples

The Pathological Narcissism Inventory (PNI) is extensively used in recent empirical literature on pathological narcissism. However, most studies using the PNI are community-based, and no studies have used the PNI to investigate narcissistic presentations in personality disordered patients. This study investigates measurement invariance of the PNI in community participants and patients with personality disorders, and examines differences of narcissistic presentations in these samples through a multimethod approach. Results show that the PNI can be used reliably to measure and compare traits of pathological narcissism in community participants and patients with personality disorders. Personality disordered patients show higher traits reflecting vulnerable narcissism and overt manifestations of grandiose narcissism, compared with controls. Finally, network analysis indicates that traits of grandiose fantasies and entitlement rage have a central role in defining manifestations of PNI pathological narcissism, regardless of the presence of an underlying personality disorder. Research and clinical implications are discussed.

Childhood emotional neglect and depressive and anxiety symptoms among mental health outpatients: the mediating roles of narcissistic vulnerability and shame

BACKGROUND

Theorized to stem from experiences of childhood emotional neglect, narcissistic vulnerability has been identified as contributing to expressions of psychiatric distress such as depressive and anxiety symptoms, particularly due to shame-proneness.

AIMS

To investigate narcissistic vulnerability and shame as mediators between perceived childhood emotional neglect and depressive and generalized anxiety symptoms among psychiatric outpatients.

METHODS

Adults (N = 137) attending community mental health services completed self-report measures at intake. Mediation analyses tested the indirect effect of perceived emotional neglect on depressive and generalized anxiety symptom severity through narcissistic vulnerability; shame was added to subsequent models to examine narcissistic vulnerability and shame as sequential mediators.

RESULTS

Perceived emotional neglect was significantly associated with narcissistic vulnerability, which in turn was linked with depressive and generalized anxiety symptoms as separate dependent variables. Indirect effects were significant in each model, indicating narcissistic vulnerability as a significant mediator. With the inclusion of shame, narcissistic vulnerability and shame were significant as sequential mediators.

CONCLUSION

Narcissistic vulnerability and shame may operate as mechanisms in conferring affective symptom severity from perceived childhood emotional neglect. Narcissistic vulnerability and susceptibility to shame may thus be important treatment targets when addressing psychological distress in the context of childhood adversity.

A Cognitive-Behavioral Formulation of Narcissistic Self-Esteem Dysregulation

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

Personality Organization and Depressive Symptoms Among Psychiatric Outpatients: The Mediating Role of Shame

ABSTRACT

Previous research has demonstrated relations between lower level of personality organization (PO) and multiple indices of mental health disturbances. The goal of this research was to examine whether experience of shame would mediate the relationship between PO and depressive symptoms in a sample of 321 Croatian psychiatric outpatients (64% female; mean age, 38.67 years). The total PO level exhibited positive associations with depressive symptoms and with all three subscales of shame ( p < 0.01). Characterological, behavioral, and bodily shame showed significant mediating effects in the PO-depression relationship, while controlling for the influence of age and sex. PO level seems to be strongly related to depressive disturbances, with the experience of shame representing one of the underlying mechanisms of this relationship. Given that patients with personality disorders ( i.e. , low PO level) suffer from poorer treatment outcomes for major mental disorders, more emphasis should be placed on psychotherapeutic management of shame-proneness.

Psychological Distress Profiles of Young Adults With Vulnerable Narcissism Traits

The current study hypothesizes a mediating role for shame in the association between vulnerable narcissism (VN) and depressive and social anxiety symptoms. A sample of 600 undergraduates was administered psychometrically sound self-reports to assess the study variables. Structural Equation Modeling supported the mediating effect of shame in the association between VN and depressive symptoms, irrespective of the way VN was assessed (i.e., Hypersensitive Narcissism Scale [HSNS] or Pathological Narcissism Inventory). Conversely, shame did not mediate the association with social anxiety when VN was assessed through the (HSNS). A direct effect of VN on both depressive and social anxiety symptoms was also detected. The results are discussed in the context of their implications, while also focusing on the different findings that emerged via the measures used to assess VN.

Investigating pathological narcissism and loneliness, and the link with life satisfaction

Loneliness is a significant health concern that may be influenced by dispositional features. Pathological narcissism may elevate loneliness through aversive interpersonal behaviors and negative social appraisals. The present study examined two dimensions of pathological narcissism, along with five-factor personality traits, in relation to loneliness among 120 young adults. Loneliness was also examined as a mediator between pathological narcissism and satisfaction with life. Narcissistic grandiosity and narcissistic vulnerability were both significantly associated with loneliness. Multiple regression analysis, including five-factor traits, revealed narcissistic vulnerability to be uniquely associated with loneliness, along with neuroticism. Mediation analysis also found an indirect effect of narcissistic vulnerability on reduced satisfaction with life, through loneliness as a mediator. These preliminary findings point to future research needs and potential clinical consideration of narcissistic vulnerability as a dispositional risk factor for loneliness.

Contemporary psychological perspectives of personality disorders

PURPOSE OF REVIEW

The aim of this study was to review the recent literature on contemporary psychological perspectives of personality disorders, including novel psychotherapeutic interventions aimed at these vulnerable individuals.

RECENT FINDINGS

Among the various psychological theories and models of personality disorders, still the most popular and researched are psychodynamic, cognitive and interpersonal perspectives. More specifically, object relations theory, cognitive schema conceptualization and interpersonal circumplex model have produced the most empirical investigations of personality disorders in recent years. Latest work has suggested that all three perspectives have contributed to and are compatible with the dimensional personality disorders framework in DSM-5-AMPD and ICD-11 (including level of personality functioning and personality traits). These models have yielded specific psychological treatments of personality disorders; although most psychotherapies have been constructed for patients with borderline personality disorder (BPD), there is an increasing number of treatment modalities aimed at individuals with other forms of personality disorder, such as those with narcissistic or antisocial traits/disorders. More research into their effectiveness and long-term benefits is necessary.

SUMMARY

Novel research keeps updating our knowledge on the cause, manifestations and psychological treatments of personality disorders, particularly from psychodynamic, cognitive and interpersonal perspectives.

It's Not That Great Anymore: The Central Role of Defense Mechanisms in Grandiose and Vulnerable Narcissism

Objectives: The concept of narcissism contains a yet unresolved paradox: Its grandiose facet depicts the psychopathological core but is often associated with life-satisfaction and overall functioning, whereas its vulnerable facet is associated with psychological distress, but still not included in the international classification systems. Our goal was to investigate the relationship between the two facets of narcissism expecting underlying defense mechanisms to be core elements. First, we aimed to identify defense mechanisms specific to grandiose and vulnerable narcissism. Second, we explored how both facets are differentially associated with psychological distress, assuming that grandiose narcissism would be associated with less psychological distress than vulnerable narcissism. Third, we investigated the mediating role of defense mechanisms between narcissism and psychological distress. Methods: In a non-clinical sample of N = 254 individuals, the Pathological Narcissism Inventory was used for the assessment of grandiose and vulnerable facets of narcissism, the Defense Style Questionnaire for defense mechanisms, and the Brief Symptom Inventory for psychological distress. Structural equation modeling was employed to identify distinct factors of grandiose and vulnerable narcissism. Associations between specific defense mechanisms and both facets were calculated. Furthermore, the direct association between both facets and psychological distress was examined. We finally explored whether defense mechanisms mediate the association between distress and both grandiose and vulnerable narcissism. Results: A distinct pattern of defense mechanisms for each facet of narcissism could be extracted: Both facets showed significant positive correlations with specific intermediate and all maladaptive defense mechanisms. Only grandiose narcissism showed significant positive correlations with adaptive defenses. Vulnerable narcissism showed negative correlations with all adaptive defenses. Specifically, grandiose narcissism was significantly related to anticipation, pseudo-altruism, rationalization, and dissociation, whereas vulnerable narcissism was negatively related to all these defense mechanisms. While grandiose narcissism was not related to psychological distress, vulnerable narcissism showed high correlations with psychological distress. Intriguingly, mediator analysis found that grandiose narcissism was related to psychological distress when mediated by maladaptive defense mechanisms. Discussion: The role of defense mechanisms is central for a differentiated understanding of the two different faces of narcissism. The relevance of assessing defense mechanisms in clinical settings, and related empirical findings are discussed.

The Association Between Vulnerable/Grandiose Narcissism and Emotion Regulation

Narcissism has been widely discussed in the context of career success and leadership. Besides several adaptive traits, narcissism has been characterized by difficulties in emotion regulation. However, despite its essential role in mental health, there is little research on emotion regulation processes in narcissism. Specifically, the investigation of not only the habitual use of specific regulation strategies but also the actual ability to regulate is needed due to diverging implications for treatment approaches. Thereby it is important to differentiate between vulnerable and grandiose narcissism as these two phenotypes might be related differently to regulation deficits. The aim of this study was to examine the association between grandiose and vulnerable narcissism and emotion regulation in healthy individuals (30f/30m) focusing on the strategy reappraisal. Additionally, potential sex effects have been explored. Narcissism was assessed using self-report measures and emotion regulation with self-report questionnaires as well as an experimental regulation task. During this task, participants were presented with pictures of sad/happy faces with the instruction to indicate their subjective emotions via button press. Depending on the condition, participants either indicated their natural response or applied cognitive control strategies to regulate their own subjective emotions. Results indicate no relationship between grandiose and vulnerable narcissism and emotion regulation ability, irrespective of sex. Individuals high on vulnerable narcissism use the maladaptive regulation strategy suppression more frequently than individuals with low expressions. Individuals high on grandiose narcissism, in contrast, seem to avoid the suppression of positive emotions and do not express negative emotions in an uncontrolled manner. Interestingly, while grandiose narcissism was not associated with depressive symptoms, vulnerable narcissism correlated positively with depressive symptoms and anhedonia. Findings of this study underline the need to differentiate between grandiose and vulnerable manifestations of narcissism. Against our expectation, narcissism was not related to emotion regulation performance. In line with previous research, grandiose narcissism seems less harmful for mental health, while vulnerable narcissism is associated with psychological problems and the use of rather maladaptive emotion regulation strategies, i.e., suppression. Future research should investigate the relationship between pathological narcissism and emotion regulation also by extending the scope to other relevant regulation strategies.

Personality and widowhood increase the risk for incident depression in the two years following the first acute coronary syndrome

Objectives: Incident depression, occurring after an acute coronary syndrome (ACS) in never depressed patients, exerts a negative effect on the cardiac prognosis. Nonetheless only a few studies have evaluated the risk factor for incident depression and, particularly, no study have investigated the role of personality disorders. Therefore, the aim of this study is to verify if personality disorders represent a risk for incident depression in patients at their first ACS.Method: The study sample was selected among never depressed patients who were consecutively admitted to the Coronary Intensive Care Unit, from January 2009 to March 2012, for the first ACS. The study sample included 262 patients. The presence of depressive disorder was assessed with the Primary Care Evaluation of Mental Disorders (DSM-IV criteria), whereas its severity was evaluated with the Hospital Anxiety and Depression Scale. Evaluations were collected at baseline and at 1, 2, 4, 6, 9, 12 and 24 months of follow-up. Moreover, at baseline personality disorders were investigated with the Structured Clinical Interview for DSM-IV Axis II disorders.Results: Out of 262 subjects, a depressive disorder was diagnosed in 56 patients (21%). At baseline risk factors for incident depression were being widowed, having a distress reaction and narcissistic personality traits.Conclusion: Clinicians should keep in mind these characteristics when facing patients at their first ACS, given the detrimental effect of depression on cardiac prognosis. A psychological support should prevent the onset of incident depression in these patients.

Internal Processing in Patients With Pathological Narcissism or Narcissistic Personality Disorder: Implications for Alliance Building and Therapeutic Strategies

Pathological narcissism (PN) and narcissistic personality disorder (NPD) have primarily been identified by striking external features, such as superiority, attention seeking and a critical or condescending attitude, and less attention has been paid to the internal processing contributing to this particular personality functioning. High dropout from treatment and challenges in building a therapeutic alliance with these patients call for further understanding of the complexity of disordered narcissism. Recent research on neuropsychological underpinnings to narcissistic pathology have provided valuable information that can inform therapeutic interventions for patients with this personality pathology. Internal processing in patients with PN or NPD is specifically influenced by compromised emotion processing and tolerance, identity diffusion, fluctuating sense of agency, reflective ability, perfectionism-related self- esteem, and ability to symbolize. The aim of this article is to review research studies with relevance for internal processing related to disordered narcissism and integrate findings with therapeutic strategies in alliance building with these patients.

Perfectionism, Shame, and Aggression in Depressive Patients With Narcissistic Personality Disorder

Depressive symptoms are known to co-occur in patients with narcissistic personality disorder (NPD). From a psychodynamic perspective, perfectionism, shame, and aggression are regarded as prominent in depressed patients. The authors investigated the occurrence of perfectionism, shame, and aggression in patients with NPD, and whether shame is a mediating or a moderating factor for aggression. Two groups of patients with depression, 61 diagnosed with NPD and no other personality disorders (PD) were compared with 56 without any PD, using the SCID screening questionnaire and a semistructured interview. All participants were administered the Multidimensional Perfectionism Scale, the Internalized Shame Scale, and the Buss-Perry Aggression Questionnaire. The NPD group showed significantly higher scores for self-oriented and socially prescribed perfectionism, shame, and aggression (i.e., physical, verbal, anger, and hostility). Shame was found to act as a mediating factor, reducing levels of aggression in patients with perfectionistic traits.

Pathological Narcissism and Symptoms of Major Depressive Disorder Among Psychiatric Outpatients: The Mediating Role of Impaired Emotional Processing

Research is scarce regarding the mechanisms by which pathological narcissism--consisting of narcissistic grandiosity and vulnerability--is linked with depression. The present study examined whether impaired emotional processing would mediate relations between pathological narcissism domains and depressive symptoms in a sample of 99 psychiatric outpatients. A significant indirect effect was found for narcissistic vulnerability on depressive symptoms, through unprocessed emotion as a mediator. Findings suggest that narcissistic vulnerability contributes to persistent and intrusive negative feelings, which in turn contribute to depressive symptom severity.

Grandiose and Vulnerable Narcissism in Borderline Personality Disorder

BACKGROUND

Little is known about narcissistic traits in borderline personality disorder (BPD). This exploratory study aimed to illustrate the associations between total, grandiose, and vulnerable narcissism and gender, diagnostic features of BPD and narcissistic personality disorder (NPD), and psychopathology in BPD patients.

SAMPLING AND METHODS

The Pathological Narcissism Inventory and psychometric measures for impulsivity, anger, borderline symptom severity, personality organization, depression, and rejection sensitivity were completed by 65 BPD patients. Statistical analyses were conducted using the t test, Pearson correlation, and multivariate regression analyses.

RESULTS

Male BPD patients displayed higher narcissistic scores than females (p < 0.01). Grandiose narcissism showed a stronger association with NPD than with BPD (p < 0.01) while vulnerable narcissism was only associated with BPD (p < 0.01). Rejection sensitivity (p < 0.01) and depression (p < 0.001) predicted vulnerable narcissism.

CONCLUSION

Vulnerable narcissism is closely associated with BPD and appears to be more dysfunctional than grandiose narcissism. A comprehensive consideration of both traits is recommended. Our results might help to generate hypotheses for further research on pathological narcissism in the spectrum of personality disorders. Future studies are advised to apply complementary measures and take new diagnostic approaches of DSM-5 and ICD-11 into account.

Vulnerable narcissism is associated with severity of depressive symptoms in dysthymic patients

Pathological narcissism involves grandiose and vulnerable presentations. Narcissism, and specifically the vulnerable presentation, has been associated to depression, although empirical research studying this relationship is limited. Dysthymia is characterized by a greater treatment resistance and poorer prognosis than other chronic depressive disorders. The presence of dysfunctional personality traits may explain it. We aim to explore the association between vulnerable narcissistic traits and severity of depressive symptoms in a sample of dysthymic patients. To that end, 80 dysthymic outpatients were evaluated. The treating psychiatrist collected sociodemographic and clinical data and completed the Clinical Global Impression-Severity Scale. Patients completed the Beck Depression Inventory (BDI) and the Hypersensitive Narcissism Scale (HSNS), that respectively assess severity of depressive symptoms and vulnerable narcissism. We tested for potential confounders and conducted a regression analysis to explore whether severity of vulnerable narcissism was associated with greater depressive symptoms. HSNS was found to be the principal predictor of BDI, and along with age, accounted for 23% of the variance in BDI. An assessment of personality functioning is therefore recommended in chronically depressed patients that have been refractory to standard treatments. Psychotherapies that address personality disturbance should be included in the treatment when necessary.

Narcissistic vulnerability is a common cause for depression in patients with Gilles de la Tourette syndrome

The aim of this study was to assess for the first time different dimensions of narcissistic self-regulation in a large cohort of adult patients with Gilles de la Tourette syndrome (GTS) (n=50). From preliminary studies it is suggested that narcissistic personality trait and disorder, respectively, are relatively uncommon and occur in only 6-10% of GTS patients. In this study we used the Narcissism Inventory (NI), a 163-items questionnaire that measures four different dimensions of narcissism. The main result was that the prevalence of narcissism strongly depends on the subtype of narcissism: while the vulnerable narcissism ("threatened self" and "hypochondriac self") was common, the "classic narcissistic self" (grandiose narcissism) was rare. From our data an association between comorbid depression and increased values of the "threatened self" and comorbid OCD with increased values of the "hypochondriac self" is suggested. Narcissism correlated positively with the personality domain neuroticism and had a significantly negative impact on patients' quality of life. Therefore it can be speculated that vulnerable narcissism is - among several others - one cause for depression in patients with GTS. These findings may open new psychotherapeutic perspectives in the treatment of depression in patients with GTS.

Narcissistic Vulnerability and Grandiosity as Mediators Between Insecure Attachment and Future Eating Disordered Behaviors: A Prospective Analysis of Over 2,000 Freshmen

OBJECTIVE

This study aimed to build on existing literature by examining the potential mediating role of two variants of narcissism (grandiosity and vulnerability) in explaining part of the underlying mechanism by which insecure (avoidant and anxiety) attachment affects behavioral elements of eating pathology (dieting and bulimic behaviors).

METHOD

Longitudinal data collected from 2,055 freshman college students (52.2% women; mean age 18.34 years) were analysed using a latent variable structural equation modelling approach, controlling for initial levels of the endogenous (i.e., dependent) latent variables and holding body mass index, anxiety, stress, depression, and self-esteem levels as time-varying covariates.

RESULTS

The effect of attachment anxiety on future bulimic behaviors was fully mediated through vulnerable narcissism (i.e., no significant direct link between attachment anxiety and bulimic behaviors), whereas grandiose narcissism fully mediated the association between attachment avoidance and future dieting behaviors. Dieting also predicted future bulimic behaviors and served as an additional (full) mediator between grandiose narcissism and bulimic behaviors. Differences in the strength of these associations across gender were not observed, and all indirect effects were statistically significant.

CONCLUSION

Overall, the findings (a) seem to support the theoretical postulations linking different insecure attachment experiences to different narcissistic tendencies, (b) imply that specific insecure attachment patterns may pass through different mediating pathways (narcissistic grandiosity and vulnerability) to specific behavioral elements of eating pathology (dieting and bulimic behaviors) regardless of gender, and (c) suggest that individuals with high grandiose narcissistic levels may not be protected from bulimic behaviors as previously indicated.