Narcissism is a popular topic in both clinical and nonclinical spheres, yet it remains indistinct from other difficult behaviors, personalities, and disorders. This literature review, after briefly reviewing the current criteria for the Diagnostic and Statistical Manual for Mental Disorders-5 diagnosis of narcissistic personality disorder, focused on current perspectives of narcissism on the subtype and trait levels. Particular attention was paid to the role subtypes and traits play in dysfunction, violence, and criminality. This review also covered current problems in clinical measurement and therapy for individuals with narcissism. It was concluded that the current diagnostic criteria for narcissistic personality disorder are incomplete and that subclinical trait narcissism better encompasses the many facets of the personality than does the formal diagnosis. Current quantitative and qualitative literature supports the multifaceted perspective of subclinical trait narcissism, which is a critical distinction for those not only in modern academia but in clinical practice and society as well.
Narcissism is a topic that has as much popular interest as it does ambiguity. From rigorous research to pop-psychology, from clinical practice to self-help podcasts, from courtrooms to barrooms—narcissism has a near-universal presence in modern parlance. It is not uncommon to find someone blurt out that another is “a narcissist” because of dislikable behavior. What one person pejoratively describes as narcissistic is debatable, but it is undoubtedly the case that narcissism creates manifold challenges.
Narcissism is a nondiagnostic term that relates to the clinical diagnosis of narcissistic personality disorder (NPD) described in the Diagnostic and Statistical Manual for Mental Disorders-5 (DSM). NPD, constituting 0-6.2% of the population (American Psychiatric Association, 2013, p. 671), is included as a cluster B personality disorder in the DSM, along with antisocial, borderline, and histrionic personality disorders—personalities that are essentially “dramatic, emotional, or erratic” (APA, 2013, p. 646). The established NPD diagnostic criteria in section II of the DSM are based on grandiosity as an essential personality feature which has rendered the diagnosis “limited by poor discriminant validity, modest levels of temporal stability, and the lowest prevalence rate on Axis II” (Cain et al., 2008, p. 650). Section III of the DSM provides a working Alternative Model that analyzes NPD on dimensions of personality functioning and traits.
As a result, there is a diagnostic caricature of narcissism as a grandiose personality as well as a heavily-researched, nondiagnostic, multifaceted portrait of narcissism, often called “subclinical” or “trait narcissism.” Much of the current research on narcissism models grandiosity as being in dynamic flux with vulnerability. Notwithstanding its importance, vulnerability has been, by turns, excluded and included in the DSM as updated editions have been published.
In the most current edition of the DSM, NPD as a whole was considered for exclusion due to ambiguity about its characterization and a commensurate dearth of research about effective treatment (Caligor et al., 2015). Indeed, treatment for the disorder remains elusive while the very structure of the pathology is under debate. While these fundamental questions remain, quantitative and qualitative research into understanding narcissism has continued, investigating even the role of narcissism in psychopathy and violence.
This literature review first introduces the DSM Section II and III profiles for NPD. The review then analyzes current ideas on grandiose and vulnerable subtypes and traits. The review concludes its analysis with current literature that links subtypes and traits with psychopathy, criminality, violence, and clinical difficulties in measurement and countertransference.
The electronic databases PubMed, ProQuest, and PsychInfo were used to search for relevant literature. Restrictions on publication date limited the preliminary search to articles written since 2007, as prompted by the assignment. The keywords used in the search were narciss* AND subtypes / narciss* AND trait* / narciss* AND comorbid* / narciss* AND violen*. Due to the popular nature of the topic and subsequent evolution in the literature, studies with more recent dates were favored for inclusion in the literature review. The references of included studies were used to locate additional articles for inclusion.
Exclusion criteria for studies were lack of peer review and sample bias (e.g. size, randomization). Sample bias was not considered among exclusion criteria for qualitative studies due to the unique value of informant reporting in describing narcissism, as detailed in the results section. For empirical studies, sample bias was considered an exclusion criterion. Due to the evolving nature of the topic, however, some articles were included if they explored a distinct area of the disorder or were very recent investigations. As a result, these articles included in the present review might best be conceived as providing preliminary data to suggest further research: Glover et al. (2012), Oltmanns et al. (2018), Rohmann et al. (2021), and Tortoriello et al. (2019).
See Appendix for two tables detailing the current DSM Section II diagnostic criteria for NPD as well as the DSM Section III Alternative Model for NPD.
While narcissism has been characterized more than fifty ways for more than fifty years across various fields, two fundamental subtypes are consistently investigated in current literature: grandiose and vulnerable narcissism. In their own ways, both the grandiose and vulnerable subtypes are “equally debilitating and clinically challenging” (Caligor et al., 2015, p. 420). While they both centralize on ego protection, they are different in response to ego threat, with the vulnerable subtype more inclined towards manifesting ego insecurity through reactive hypersensitivity and neuroticism.
Recently, Rohmann et al. (2021) patternized grandiose and vulnerable subtypes utilizing agency and self-esteem measures. “Positive agency” is a self-confident way of relating to others, and “negative agency” is a hostile way of relating to others (p. 4843). The vulnerable subtype was consistently correlated with low self-esteem which was mediated by both low positive agency and high negative agency. The grandiose subtype was characterized by high negative agency, like the vulnerable subtype, but also by high positive agency. When acting with high positive agency, the grandiose subtype was correlated with high self-esteem. When acting with high negative agency, the grandiose subtype was correlated with low self-esteem. In such a way, the two subtypes have distinct profiles of behavior and self-regard.
From the subtype level, narcissism has been characterized and measured on a granular trait level. Common traits include reactive anger, shame, indifference, need for admiration, exhibitionism, thrill-seeking, authoritativeness, grandiose fantasies, cynicism/distrust, manipulativeness, exploitativeness, entitlement, arrogance, lack of empathy, and acclaim-seeking (Glover et al., 2012, p. 502). These and other traits link not only to subtypes (e.g. arrogance as a trait of the grandiose subtype) but to other personality dimensions as well.
From a foundation of subtypes and traits, narcissism has been scaled up to a multifaceted psychological profile. In the recent Narcissism Spectrum Model (Krizan & Herlache, 2018), various traits of narcissism were shown to map dynamically, “by extremity and expression” (p.16), with grandiosity and vulnerability along the central dimension of entitlement as well as with other factors of personality (e.g. grandiosity correlated with extraversion). Furthermore, narcissistic traits have been linked to differential social adaptiveness, wherein high-functioning narcissists utilize their “exhibitionistic” traits for social advancement while malignant narcissists utilize “sadistic” traits to control others (Caligor et al., 2015, pp. 416-418). As such, narcissism can be hard to discriminate from other personality styles and disorders on the trait level, and there is a high comorbidity rate with other diagnoses. Indeed, NPD cannot be easily discriminated even from the ever-vilified antisocial personality disorder (Roepke & Vater, 2014).
While psychopathy is conventionally linked to antisocial personality disorder, psychopathy has been conceptualized as a distinct construct to which the traits of narcissism can be applied. Martinez et al. (2019) discriminated narcissistic psychopathy from antisocial psychopathy on the trait level. Specifically, “reward dependence” and “self-directedness” (e.g. control over reactivity) are higher in narcissistic psychopathy, while “novelty seeking” (e.g. impulsivity) and “self-transcendence” (i.e. self-awareness) are higher in antisocial psychopathy (p. 7-8). Notably, the authors opine that individuals with narcissistic psychopathy profiles tend to have more social achievement than individuals with antisocial psychopathy profiles by utilizing “charm, charisma, and manipulation” (p. 7). Indeed, prosocial qualities can be used in the service of antisocial behavior.
In spite of adaptive social traits in individuals with narcissism, narcissism is linked to criminality and violence, including homicide. Hepper et al. (2014) found that incarcerated individuals are more narcissistic than individuals in community samples, and incarcerated individuals demonstrate more subclinical trait narcissism than clinical NPD. Furthermore, the trait most strongly linked to incarceration was entitlement. With regard to violence specifically, Lambe et al. (2018) found that there is a strong link between narcissism and violence, particularly severe violence, as a result of ego threat. The underlying personality factor in narcissism that predicts violence is unstable self-esteem, for which violence functions as a restorative mechanism.
Of the two fundamental subtypes, the vulnerable subtype is linked with criminality and aggression more than the grandiose subtype. Bogaerts et al. (2021) found that the vulnerable subtype, with its “identity diffusion,” or lack of identity that is “stable, integrated, and purposive” (p. 2), and consequent lack of self-control, was associated with more criminality than the grandiose subtype. Rasmussen’s recent 2022 meta-analysis suggested a propensity for the vulnerable subtype to be the more vengeful subtype, likely due to low self-esteem.
With regard to intimate partner violence and dysfunction, subclinical trait narcissism is often implicated, with the vulnerability trait posing the most dysfunction. Green and Charles (2019) found that interviews with victims are helpful in disentangling presentations of grandiose and vulnerable traits in individuals with narcissism who perpetrate intimate partner violence. Specifically, when victims challenged authority, the perpetrators’ grandiose traits (e.g. rageful demanding) emerged while their vulnerable traits (e.g. false victimization) emerged when the victims were perceived to be leaving the relationship. With regard to reactions to romantic infidelity, the grandiose subtype was found to be “cooler” than the “hot” vulnerable subtype (Tortoriello & Hart, 2019, p. 2159). The grandiose subtype enacts “attacking/restricting tactics” to regain power while the vulnerable subtype enacts both “attack/restricting tactics” and “[relationship-]enhancing tactics” in order to regain power and self-esteem (p. 2172). With such mixed motives, the vulnerable subtype is more “insidious,” consistent with the informant narratives in the qualitative study by Day et al. (2020, p.1). Through the lens of the informants, the vulnerability trait expressions of perpetrators ranged from “…he’s told me that I’m a worthless person and I should kill myself…” (p. 6) to “When I state I can’t take any more or say we can’t be together…he threatens to kill himself” (p. 7). Understanding these tactics as common to the vulnerable subtype helps clarify this apparently bewildering volte-face.
Glover et al. (2012) identified fifteen traits of narcissism, by subtype, that are differentially detected by various existing measures of narcissism. Using these traits, they found that different measures account for traits and subtypes differently. For instance, the grandiosity detected and characterized on the trait level by one measure differed from the grandiosity detected and characterized on the trait level by another measure. Out of all the measures, they suggested that the Five-Factor Narcissism Inventory (FFNI) was most powerful in disambiguating trait subtleties.
While the FNNI is based on self-report, Oltmanns et al. (2018) went on to suggest the complimentary value of an informant version of the FFNI (IFFNI) for understanding subtypes and traits. The IFFNI is particularly useful due to “the degree of distortion in self-description inherent to narcissism” (p. 31). For example, using convergence data from the FFNI and IFFNI on grandiosity traits, the researchers found that individuals with narcissism were likely to self-report that their narcissistic traits were adaptive rather than dysfunctional as portrayed by the informants.
While the use of current measures of narcissism remains unstandardized, the typical therapeutic relationship between counselors and individuals with narcissism presents difficulty as well. Tanzilli and Gualco (2020) linked the subtypes with specific countertransference patterns in therapeutic relationships. The vulnerable subtype predicted an “overinvolved/worried” (p. 42) therapist response. Specifically, the therapists felt “depressiveness and anxiety; feelings of inadequacy and difficulty in working with the patient; a strong sense of concern…problems in maintaining boundaries; a sense of being devalued; and unexpressed rage” (p. 54). The grandiose subtype predicted a “angry/criticized and disengaged/hopeless” therapist response (p.42). Specifically, the therapists felt “rage, mistrust, and frustration; a strong sense of devaluation and criticism by the patient; feelings of helplessness and failure to help patients; and withdrawal” (p. 54). Across all dimensions, subtypes, and traits, individuals with narcissism consistently beguile efforts of measurement and treatment.
Everybody knows what narcissism is, but nobody knows what narcissism is. Perhaps the biggest weakness in the current, and abundant, body of literature is that there is no standardized concept of narcissism. Diagnosis, subtypes, traits, presentations, dimensions—there is an array of terms describing how the personality is organized. Without a standard to hang our hat on, investigation into, measurement of, and treatment of narcissism remain postulatory.
A strength in the current body of literature about narcissism is the widely-accepted working models of grandiose and vulnerable subtypes. This perspective adds breadth to the current DSM section II diagnostic criteria for NPD. Empirical and qualitative studies, especially those using informant narratives, are helpful concomitants in understanding the working models as accurate self-reporting and measures of narcissism, while illustrative, remain equivocal.
A weakness in the current body of literature is that while many measures can detect narcissism, different measures highlight different features of narcissism (Glover et al., 2012; Krizan and Herlache, 2018). No gold-standard measure or diagnostic protocol is utilized routinely. With modern, evidence-based, gold-standard measures and protocols, replication of existing analyses could be performed to help standardize the diagnosis. For the nonce, clinical application of appropriate measures remains problematic, as does the therapeutic relationship itself. This is particularly pertinent given the implications of narcissism’s role in antisocial and criminal behavior.
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Typical features of narcissistic personality disorder are variable and vulnerable self-esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Antagonism.
A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem.
2. Self-direction: Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
3. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others' experiences and predominance of a need for personal gain.
B. Both of the following pathological personality traits:
1. Grandiosity (an aspect 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 (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking.