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Day NJS, Green A, Denmeade G, Bach B, Grenyer BFS. Narcissistic personality disorder in the ICD-11: Severity and trait profiles of grandiosity and vulnerability. J Clin Psychol 2024; 80:1917-1936. [PMID: 38742471 DOI: 10.1002/jclp.23701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 05/16/2024]
Abstract
Modern diagnostic and classification frameworks such as the ICD-11 and DSM-5-AMPD have adopted a dimensional approach to diagnosing personality disorder using a dual "severity" and "trait" model. As narcissistic personality has historically struggled to be adequately captured in dominant diagnostic systems, this study investigated the utility of the new ICD-11 framework in capturing diverse narcissistic expressions. Participants were mental health clinicians (N = 180, 67% female, age = 38.9), who completed ratings of ICD-11 personality severity, trait domains and a clinical reflection for two hypothetical case vignettes reflecting either prototypical "grandiose" or "vulnerable" narcissism. The majority of clinicians (82%) endorsed a diagnosis of personality disorder for both grandiose and vulnerable vignettes. Discriminant elements of personality impairment included rigid, unrealistically positive self-view, low empathy and high conflict with others for grandiosity, and incoherent identity, low self-esteem and hypervigilant, avoidant relations with others for vulnerability. Regarding trait profile, grandiose narcissism was predominately dissocial whereas vulnerable narcissism was primarily associated with negative affectivity and detachment. Qualitative responses highlight distinct clinical themes for each presentation. These findings suggest that clinicians using the ICD-11 framework are able to identify common core elements of personality dysfunction in grandiose and vulnerable narcissism while also recognizing their distinctive differences.
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Affiliation(s)
- Nicholas J S Day
- School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia
| | - Ava Green
- Department of Psychology, City, University of London, London, UK
| | - Georgia Denmeade
- School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia
| | - Bo Bach
- Psychiatric Research Unit, Mental Health Services, Center for Personality Disorder Research, Region Zealand, Denmark
| | - Brin F S Grenyer
- School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia
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Green A, MacLean R, Charles K. Clinician perception of pathological narcissism in females: a vignette-based study. Front Psychol 2023; 14:1090746. [PMID: 37151338 PMCID: PMC10157482 DOI: 10.3389/fpsyg.2023.1090746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
The DSM-5 reports that up to 75% of those diagnosed with Narcissistic Personality Disorder (NPD) are males, which denotes that narcissism is a clinical phenomenon that operates differently in men and women. Vulnerable narcissism, which tends to be more prevalent in females and is currently under-appreciated in the DSM-5, may be diagnosed as other "vulnerable" disorders (e.g., Borderline Personality Disorder; BPD). The current study investigated gender differences in clinicians' perceptions of narcissistic pathology. Adopting an online vignette-based study, clinicians (N = 108; 79 females) read clinical case vignettes of hypothetical patients and provided diagnostic ratings of existing personality disorders. Clinicians' diagnostic ratings of NPD were concurrent with the vignette containing grandiose narcissism symptoms, irrespective of patient gender. However, when presented with a vulnerable narcissism vignette, clinicians were significantly more likely to attribute a BPD diagnosis in female patients, compared to male patients. Clinicians with a psychodynamic approach and more experience in practice were also more likely to label vulnerable narcissism symptoms as NPD, compared to those with a CBT approach and less experience in practice. The clinical implications of these results support the shift toward assessing personality dysfunction based on dimensional trait domains.
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Affiliation(s)
- Ava Green
- Department of Psychology, City, University of London, London, United Kingdom
- *Correspondence: Ava Green,
| | - Rory MacLean
- Department of Psychology, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Kathy Charles
- Centre for Academic Development and Quality, Nottingham Trent University, Nottingham, United Kingdom
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Abstract
Despite putative gender differences in the expression of narcissism, prominent theories have virtually dismissed the role of females in the development and manifestation of narcissism. The contention that narcissism is a pathology of the self that may partly differ in males and females is further evident in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 reports that up to 75% of those diagnosed with Narcissistic Personality Disorder (NPD) are men. Such figures suggest that the representation of narcissism as codified in the DSM-5 may only be marginally applicable to females, given its prominent focus and nature on capturing grandiose themes which closely resemble commonly masculine norms. The overemphasis on grandiose features extends to the empirical literature which defines narcissism as a normative personality trait and is widely assessed using the Narcissistic Personality Inventory (NPI), on which males obtain significantly higher scores than females. As this review will demonstrate, one limitation frequently occurring in the literature is the attempt to comprehend narcissistic manifestations in females through the lens of what has commonly been defined as narcissism (DSM/NPI). In this review, the literature concerning the diagnostic assessment and conceptualisation of narcissistic personality disorder, aetiological factors, aggression, and partner violence perpetration will be discussed in relation to the importance of gender. This is followed by a review of existing gaps in theory and research, and suggestions for fruitful directions that can aid a richer and more meaningful literature on narcissism inclusive of gender issues.
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Affiliation(s)
- Ava Green
- City University of London, Department of Psychology, London, UK
| | - Rory MacLean
- Edinburgh Napier University, School of Applied Sciences, Edinburgh, UK
| | - Kathy Charles
- Nottingham Trent University, Centre for Academic Development and Quality, Nottingham, UK
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Pedersen G, Wilberg T, Hummelen B, Hartveit Kvarstein E. The Norwegian network for personality disorders - development, contributions and challenges through 30 years. Nord J Psychiatry 2022:1-9. [PMID: 36409693 DOI: 10.1080/08039488.2022.2147995] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Established in 1992, the Norwegian Network for Personality Disorders (The Network) is a clinical research collaboration of specialist mental health and addiction services in Norway. Its primary focus is to facilitate systematic and relevant clinical assessment for patients with personality disorder and evaluate progress in psychotherapeutic treatment. However, large-scale data registers for personality disorder are still unique. This article presents the circumstances that led to the establishment of the Network, and its development and challenges in many areas, and through various phases. METHODS In the following, we will outline how this close interaction between researchers, clinicians, and well-adapted systems has facilitated cooperation and clinical research. We will highlight some key factors that have been decisive during the network's development, and not least for further adaptation and existence. RESULTS Through 30 years, the Network has succeeded in establishing a large and sustainable clinical research collaboration with a persistent focus on personality disorder and psychotherapeutic treatment. The collaboration has resulted in a broad range of scientific contributions to the understanding of personality disorder, assessment and measurement methods, treatment alliance, clinical outcomes, service utilization, and costs. In addition, The Network has also resulted in a number of synergy effects that have benefited clinicians, patients, and researchers. CONCLUSIONS The Norwegian Network for Personality Disorders has become an acknowledged institution in the field. Many aspects of its development, organization, maintenance, and solutions to challenges may be relevant to others who plan to establish, maintain, or further develop similar collaborations.
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Affiliation(s)
- Geir Pedersen
- Section for Personality Psychiatry and Specialized Treatments, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.,The Norwegian Centre of Mental Disorders Research (NORMENT), Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Theresa Wilberg
- Department of Research and Innovation, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Benjamin Hummelen
- Department of Research and Innovation, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Elfrida Hartveit Kvarstein
- Section for Personality Psychiatry and Specialized Treatments, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Jacobs KA. The concept of Narcissistic Personality Disorder-Three levels of analysis for interdisciplinary integration. Front Psychiatry 2022; 13:989171. [PMID: 36465294 PMCID: PMC9709503 DOI: 10.3389/fpsyt.2022.989171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/31/2022] [Indexed: 11/17/2022] Open
Abstract
In this paper, I distinguish three different levels for describing, and three corresponding ways for understanding, deficient empathy as the core of NPD (Narcissistic Personality Disorder). On the macro level, deficient empathy can be explained as disturbed interpersonal functioning, and is understood as lack of recognition. On the meso-level, deficient empathy can be described as psychic disintegration, and can be understood specifically in its dissocial aspects. Psychic disintegration in NPD correlates with somatic changes, i.e., dysfunctional affective empathy and mind-reading on the micro level of description, which is the third level. The "core-deficit-model of NPD" that I outline, while not rejecting reductionist approaches outright, argues in favor of integrating (top-down/bottom-up) functionalist descriptions of empathy into a wider conceptual framework of bio-psycho-social functioning. The "core-deficit-model of NPD" is interdisciplinary, can bypass monodisciplinary skepticism, and removes purported barriers between explaining and understanding the "lack" of empathy as the core of pathological narcissism.
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Affiliation(s)
- Kerrin A. Jacobs
- Department of Philosophy and Ethics, Faculty of Humanities and Human Sciences, University of Hokkaido, Sapporo, Japan
- Center for Human Nature, Artificial Intelligence, and Neuroscience (CHAIN), University of Hokkaido, Sapporo, Japan
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Popolo R, MacBeth A, Brunello S, Canfora F, Ozdemir E, Rebecchi D, Toselli C, Venturelli G, Salvatore G, Dimaggio G. Metacognitive interpersonal therapy in group: a feasibility study. RESEARCH IN PSYCHOTHERAPY (MILANO) 2018; 21:338. [PMID: 32913773 PMCID: PMC7451332 DOI: 10.4081/ripppo.2018.338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/10/2018] [Indexed: 11/23/2022]
Abstract
Patients with personality disorders (PDs) other than borderline, with prominent features of social inhibition and over-regulation of emotions, are in need of specialized treatments. Individuals present with poor metacognition, that is the capacity to understand mental states and use psychological knowledge for the sake of purposeful problem solving; and are guided by maladaptive interpersonal schemas. We developed a short-term group intervention, Metacognitive Interpersonal Therapy in Groups (MIT-G), incorporating psychoeducational and experiential elements, to help these individuals become more aware of their drives when interacting with others; and to help them adopt more flexible behaviors via improvements in metacognition. We present results of an effectiveness study, evaluating whether we could replicate the initial positive results of our first pilot randomized controlled trial. Seventeen young adults outpatients with personality disorders were included in the 16 session program. Effect sizes were calculated for change from baseline to treatment end for the primary outcome, symptoms and functioning (Clinical Outcomes in Routine Evaluation Outcome Measure) and then for one putative mechanism of change - metacognition. Emotional dysregulation and alexithymia were also assessed. Qualitative evaluations of the acceptability and subjective impact of the treatment were also performed. MIT-G was acceptable to participants. There were medium to large magnitude changes from pre- to post- treatment on wellbeing, emotion dysregulation, alexithymia and metacognition. These gains were maintained at follow-up. There was evidence of clinically significant change on key variables. MITG appears acceptable to patients, as evidenced by the absence of drop-out from treatment. In light of the positive outcomes of this study and the expanding evidence base, MIT-G is a candidate for dissemination and investigations in larger trials as a possible effective intervention for PDs characterized by tendencies to overcontrol.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Giampaolo Salvatore
- Centro di Terapia Metacognitiva Interpersonale, Rome, Italy
- Scuola di Specializzazione “Humanitas”, Rome, Italy
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Hoertel N, Peyre H, Lavaud P, Blanco C, Guerin-Langlois C, René M, Schuster JP, Lemogne C, Delorme R, Limosin F. Examining sex differences in DSM-IV-TR narcissistic personality disorder symptom expression using Item Response Theory (IRT). Psychiatry Res 2018; 260:500-507. [PMID: 29291575 PMCID: PMC6002876 DOI: 10.1016/j.psychres.2017.12.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/25/2017] [Accepted: 12/12/2017] [Indexed: 12/30/2022]
Abstract
The limited published literature on the subject suggests that there may be differences in how females and males experience narcissistic personality disorder (NPD) symptoms. The aim of this study was to use methods based on item response theory to examine whether, when equating for levels of NPD symptom severity, there are sex differences in the likelihood of reporting DSM-IV-TR NPD symptoms. We conducted these analyses using a large, nationally representative sample from the USA (n=34,653), the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). There were statistically and clinically significant sex differences for 2 out of the 9 DSM-IV-TR NPD symptoms. We found that males were more likely to endorse the item 'lack of empathy' at lower levels of narcissistic personality disorder severity than females. The item 'being envious' was a better indicator of NPD severity in males than in females. There were no clinically significant sex differences on the remaining NPD symptoms. Overall, our findings indicate substantial sex differences in narcissistic personality disorder symptom expression. Although our results may reflect sex-bias in diagnostic criteria, they are consistent with recent views suggesting that narcissistic personality disorder may be underpinned by shared and sex-specific mechanisms.
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Affiliation(s)
- Nicolas Hoertel
- Assistance Publique Hôpitaux de Paris (APHP), Western Paris University Hospitals, Department of Psychiatry, 92130 Issy-les-Moulineaux, France; INSERM UMR 894, Psychiatry and Neurosciences Center, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France.
| | - Hugo Peyre
- Assistance Publique Hôpitaux de Paris (APHP), Robert Debré Hospital, Child and Adolescent Psychiatry Department, Paris, France; Cognitive Sciences and Psycholinguistic Laboratory, Ecole Normale Supérieure, Paris, France
| | - Pierre Lavaud
- Assistance Publique Hôpitaux de Paris (APHP), Western Paris University Hospitals, Department of Psychiatry, 92130 Issy-les-Moulineaux, France
| | - Carlos Blanco
- Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse, Bethesda, ML, USA
| | - Christophe Guerin-Langlois
- Assistance Publique Hôpitaux de Paris (APHP), Western Paris University Hospitals, Department of Psychiatry, 92130 Issy-les-Moulineaux, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Margaux René
- Assistance Publique Hôpitaux de Paris (APHP), Western Paris University Hospitals, Department of Psychiatry, 92130 Issy-les-Moulineaux, France
| | - Jean-Pierre Schuster
- Assistance Publique Hôpitaux de Paris (APHP), Western Paris University Hospitals, Department of Psychiatry, 92130 Issy-les-Moulineaux, France; Service of Old Age Psychiatry, Department of Psychiatry, Lausanne University Hospital, Prilly, Switzerland
| | - Cédric Lemogne
- Assistance Publique Hôpitaux de Paris (APHP), Western Paris University Hospitals, Department of Psychiatry, 92130 Issy-les-Moulineaux, France; INSERM UMR 894, Psychiatry and Neurosciences Center, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Richard Delorme
- Assistance Publique Hôpitaux de Paris (APHP), Robert Debré Hospital, Child and Adolescent Psychiatry Department, Paris, France
| | - Frédéric Limosin
- Assistance Publique Hôpitaux de Paris (APHP), Western Paris University Hospitals, Department of Psychiatry, 92130 Issy-les-Moulineaux, France; INSERM UMR 894, Psychiatry and Neurosciences Center, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
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Abstract
PURPOSE OF REVIEW This review summarizes recent executive functions research to better delineate the nosology of personality disorders. RECENT FINDINGS This review indicates that there are consistent impairments in executive functioning in people with personality disorders as compared with matched controls. Only five disorders were considered: borderline, obsessive-compulsive, antisocial, narcissistic, and schizotypal. Significant deficits are observed in decision-making, working memory, inhibition, and flexibility. Relevant data for the remaining personality disorders have not yet been published in relation to the executive functions. SUMMARY People with personality disorders could present a pattern of neurocognitive alterations that suggest a specific impairment of the prefrontal areas. The executive dysfunctions could partially explain the behavioral alterations in people with personality disorders.Further research should adopt broader considerations of effects of comorbidity and clinical heterogeneity, include community samples and, possibly, longitudinal designs with samples of youth.
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Roepke S, Vater A. Narcissistic personality disorder: an integrative review of recent empirical data and current definitions. Curr Psychiatry Rep 2014; 16:445. [PMID: 24633939 DOI: 10.1007/s11920-014-0445-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Although concepts of pathological narcissism are as old as psychology and psychiatry itself, only a small number of clinical studies are based on the criteria for narcissistic personality disorder (NPD), as defined in the Diagnostic and Statistical Manuals of Mental Disorders (DSM). As a result, NPD appears to be one of the most controversially discussed nosological entities in psychiatry. Whereas the majority of empirical studies used self or other ratings of NPD criteria to address issues of reliability and validity of the diagnostic category (i.e., internal consistency, factor structure, discriminant validity), only recent research has applied experimental designs to investigate specific features of NPD (e.g., self-esteem, empathy, shame). The aim of this review is to summarize available empirical data on NPD and relate these findings to current definitions of NPD (according to the DSM-5, [1]). In order to do so, this review follows the five steps to establishing diagnostic validity proposed by Robins and Guze [2], i.e., (1) clinical description, (2) laboratory studies, (3) delimitation from other disorders, (4) family studies, and (5) follow up studies. Finally, this review suggests pathways for future research that may assist further nosological evaluation of NPD and contribute to the overall goal, the improvement of treatment for patients.
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Affiliation(s)
- Stefan Roepke
- Department of Psychiatry, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Eschenallee 3, 14050, Berlin, Germany,
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Abstract
PURPOSE OF REVIEW The present review examines the decision of the DSM-5 Personality and Personality Disorders Working Group to retain or to remove specific personality disorders included in DSM-IV-TR and presents the reactions elicited by the decision and published between 10 February 2010 and 30 September 2012. RECENT FINDINGS In the first draft of Chapter P (Personality disorders), posted on the DSM-5 Internet site on 10 February 2010, the DSM-5 Personality and Personality Disorders Working Group proposed to remove paranoid, schizoid, histrionic, dependent and narcissistic personality disorders from the classification. A revised version of the draft, posted on the Internet in June 2011, reinstated narcissistic personality disorder but not the four remaining types that had been slated for removal. Underlying the decision of the Work Group for retaining versus removing specific personality disorder types are arguments concerning the clinical utility and validity of each type. The arguments provided by the Work Group have not been accepted unanimously by other personality disorder experts. SUMMARY DSM-5 will retain six out of the 10 personality disorder types listed in DSM-IV-TR while removing the remaining four types. Reactions to the decision and to the arguments presented for doing so have been mixed.
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