Personality Disorders: Theory, Research, and Treatment 2014, Vol. 5, No. 2, 230 –231
© 2014 American Psychological Association 1949-2715/14/$12.00 DOI: 10.1037/per0000009
COMMENTARY
Ruminations on Narcissistic Personality Disorder Timothy J. Trull
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Missouri
there is no compelling evidence that mean levels of extraversion, antagonism, or the first-order traits mentioned above have risen dramatically over the last 20 –30 years (with the exception perhaps of extraversion in college students; Twenge, 2001). The primary basis for concluding that rates of narcissism are rising is college students’ mean scores on the Narcissistic Personality Inventory (NPI; Raskin & Terry, 1988) over several decades (Twenge & Foster, 2010). The NPI, although perhaps tapping into traits underlying narcissism, is not a diagnostic measure and there is even controversy over how well it performs as a measure of narcissism (Cain, Pincus, & Ansell, 2008; Rosenthal et al., 2011). Furthermore, scoring high on trait measures does not necessarily translate into impairment or dysfunction, which is typically required for a designation of personality pathology or disorder. Those of us who have taught undergraduates over the last several decades certainly recognize that students now seem somewhat more self-focused than two decades ago, but that does not necessarily translate into NPD. Aside from the issue of whether we are witnessing an increase in NPD and narcissism in Western society, there is another issue. Are our current approaches to the measurement of NPD sufficient? Here, I highlight two alternative assessment approaches that may be especially useful in the assessment of NPD (and other PDs as well). First, an underutilized assessment method in personality disorders is that of peer assessment (Oltmanns & Turkheimer, 2009). If pathological personality traits are primarily ego-syntonic (as Paris [2014] suggests is the case in NPD), then it seems less likely that individuals will accurately self-report either high, maladaptive levels of the traits or problems associated with the traits. For example, Carlson, Vazire, and Oltmanns (2011) recently reported on three studies aimed at evaluating how aware individuals with narcissism are regarding negative aspects of their personality and reputation. Although these studies did not include patients with NPD, the findings seem relevant. First, those high in narcissism do view themselves positively, but they also seem to appreciate that others do not see them as positively as they see themselves. However, despite the awareness of this more negative external evaluation from others, results were consistent with the view that those with narcissism view their own narcissistic traits as positive. Second, individuals with narcissism appear to make a good first impression initially that then deteriorates over time. Overall, these findings suggest that a multipronged approach to the assessment of NPD is needed—self-reports alone do not capture the full picture and longitudinal data may be necessary to assess relationship disruptions and dissolutions.
Paris (2014, pp. 220 –226) provides an interesting and provocative overview of the diagnosis, etiology, and treatment of narcissistic personality disorder (NPD). In particular, his article focuses on the potential sociocultural influences on the prevalence of this disorder, recent arguments that narcissism in general and NPD in particular are on the rise because of cultural influences, and the possibility that standard forms of psychotherapy may actually serve to maintain or even exacerbate NPD. As Paris (2014) notes, NPD has recently received more attention from the mental health community for two reasons. First, many papers, articles, and books suggesting that narcissism and NPD are increasing in prevalence at alarming rates have been published over the last 10 years. Second, when the initial DSM-5 proposal to delete NPD from the nomenclature appeared, many scholars, researchers, and clinicians came to this construct’s defense, bringing NPD back into the limelight. In this commentary, I focus on several assessment issues for narcissism, as well as NPD in particular. One issue that Paris (2014) highlighted is the apparent disagreement about the prevalence of NPD. On the one hand, we have scholars talking about narcissism (and NPD by extension) reaching epidemic proportions; on the other hand, there is little evidence from large clinical or nonclinical samples, assessed via structured interview, that the prevalence of NPD is high (or higher than most PDs). So, what is the actual prevalence of NPD? Almost all large, epidemiological studies of NPD suggest that the prevalence of this disorder is about 1% (Trull, Jahng, Tomko, Wood, & Sher, 2010). It is also worth noting that even studies of clinical samples do not report particularly high rates of NPD (e.g., less than 3%; Zimmerman, Rothschild, & Chelminski, 2005). Adopting a trait perspective, there does not seem to be sufficiently strong evidence to conclude there has been a major rise in rates of narcissism or narcissistic traits either. NPD is related primarily to low levels of agreeableness (i.e., antagonism) and higher levels of extraversion (Samuel & Widiger, 2008; Saulsman & Page, 2004). Concerning lower-order personality traits, NPD is significantly associated with lower levels of trust, straightforwardness, altruism, compliance, and modesty; NPD is also significantly associated with higher levels of angry hostility (Samuel & Widiger, 2008). In the DSM-5 draft proposal, NPD is characterized by only two personality traits, grandiosity and attention-seeking. Although levels of personality traits do change over the life span,
Correspondence concerning this article should be addressed to Timothy J. Trull, Department of Psychological Sciences, 210 McAlester Hall, University of Missouri, Columbia, MO 65211. E-mail: [email protected] 230
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
COMMENTARY
Another approach that can shed light on the interpersonal behavior of those with narcissism is the use of naturalistic observation. For example, the Electronically Activated Recorder (EAR; Mehl et al., 2001) captures ambient sounds in an individual’s natural environment using a small computer or mobile phone as the recording device. This ambulatory assessment method has already been used to study psychopathology related to depression and borderline personality disorder (e.g., Tomko et al., in press). The EAR can be worn or carried in daily life unobtrusively, and the recordings can be coded for activities (working, talking), environment (in car, at a restaurant), interpersonal context (with others or alone), affect, and word use, for example. What might EAR recordings tell us about NPD in daily life? Holtzman, Vazire, and Mehl (2010) recently reported EAR findings in a sample of undergraduates, some of whom scored high on narcissistic traits. Positive correlations were found between narcissistic traits and extraverted/positive acts (e.g., talking, being in a group, socializing, and using words related to friendship), disagreeable acts (e.g., arguing, using swear words, using anger words), and use of sexual language. These findings indicate that narcissistic traits are associated with both positive and negative acts, perhaps reflecting the difficulty clinical researchers and clinicians experience in identifying the problems and impairment one might expect to be associated with narcissism and NPD. In closing, I want to highlight some implications for the clinical assessment of NPD. First, it seems clear that traditional clinical assessment approaches for NPD are inadequate. The self-reports of those with NPD do not tell the whole story, and those with NPD may be unable to accurately label their interpersonal impact on others as negative or dysfunctional. Yes, they recognize that others may not hold them in as high regard as they hold themselves, but that does not translate into being aware of the negative impact of their own behavior. In addition, cross-sectional assessments will not be able to adequately capture the interpersonal pattern associated with NPD: initially, the friendly extravert that is sought out by others; later, the relationship partner who is too self-focused and perhaps disparaging; and, finally, the person who ends the relationship or causes the previous “friend” to feel used or neglected. There is clearly a benefit to gathering data from peers, family members, or significant others who know the person well over a period of time. Second, new assessment methods that sample the everyday life of individuals may be particularly well-suited to reveal aspects of NPD that cannot be captured adequately by traditional clinical questionnaires and interviews. The dysfunction associated with NPD is manifested in everyday life, and neither lab studies nor cross-sectional self-reports are able to reliably capture what happens in the real world. Another advantage of ambulatory assessment methods is that individuals choose what they do in daily life and with whom they spend time, enhancing ecological validity. Furthermore, ambulatory assessment avoids the reliance on reports of what individuals remember retrospectively or what they believe they are like. Therefore, ambulatory assessment holds
231
great promise in the assessment of the real-world correlates of narcissistic traits and NPD.
References 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. Carlson, E. N., Vazire, S., & Oltmanns, T. F. (2011). You probably think this paper’s about you: Narcissists’ perceptions of their personality and reputation. Journal of Personality and Social Psychology, 101, 185–201. Holtzman, N. S., Vazire, S., & Mehl, M. R. (2010). Sounds like a narcissist: Behavioral manifestations of narcissism in daily life. Journal of Research in Personality, 44, 478 – 484. Mehl, M. R., Pennebaker, J. W., Crow, D. M., Dabbs, J., & Price, J. H. (2001). The Electronically Activated Recorder (EAR): A device for sampling naturalistic daily activities and conversations. Behavior Research Methods Instruments & Computers, 33, 517–523. Oltmanns, T. F., & Turkheimer, E. (2009). Person perception and personality pathology. Current Directions in Psychological Science, 18, 32–36. Paris, J. (2014). Modernity and narcissistic personality disorder. Personality Disorders: Theory, Research, and Treatment, 5, 220 –226. doi: 10.1037/a0028580 Raskin, R., & Terry, H. (1988). A principal-components analysis of the Narcissistic Personality Inventory and further evidence of its construct validity. Journal of Personality and Social Psychology, 54, 890 –902. Rosenthal, S. A., Montoya, R. M., Ridings, L. E., Rieck, S. M., & Hooley, J. M. (2011). Further evidence of the Narcissistic Personality Inventory’s validity problems: A meta-analytic investigation: Response to Miller, Maples, and Campbell. Journal of Research in Personality, 45, 408 – 416. Samuel, D. B., & Widiger, T. A. (2008). A meta-analytic review of the relationships between the five-factor model and DSM–VI–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. Tomko, R. L., Brown, W. C., Tragesser, S. L., Wood, P. K., Mehl, M. R., & Trull, T. J. (in press). Social Context of Anger in Borderline Personality Disorder and Depressive Disorders: Findings from a Naturalistic Observation Study. Journal of Personality Disorders. 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, 412– 426. Twenge, J. M. (2001). Birth cohort changes in extraversion: A crosstemporal meta-analysis, 1966 –1993. Personality and Individual Differences, 30, 735–748. Twenge, J. M., & Foster, J. D. (2010). Birth cohort increases in narcissistic personality traits among American college students, 1982–2009. Social Psychological and Personality Science, 1, 99 –106. Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of DSM–IV personality disorders in psychiatric outpatients. American Journal of Psychiatry, 162, 1911–1918.
© 2014 American Psychological Association 1949-2715/14/$12.00 DOI: 10.1037/per0000009
COMMENTARY
Ruminations on Narcissistic Personality Disorder Timothy J. Trull
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Missouri
there is no compelling evidence that mean levels of extraversion, antagonism, or the first-order traits mentioned above have risen dramatically over the last 20 –30 years (with the exception perhaps of extraversion in college students; Twenge, 2001). The primary basis for concluding that rates of narcissism are rising is college students’ mean scores on the Narcissistic Personality Inventory (NPI; Raskin & Terry, 1988) over several decades (Twenge & Foster, 2010). The NPI, although perhaps tapping into traits underlying narcissism, is not a diagnostic measure and there is even controversy over how well it performs as a measure of narcissism (Cain, Pincus, & Ansell, 2008; Rosenthal et al., 2011). Furthermore, scoring high on trait measures does not necessarily translate into impairment or dysfunction, which is typically required for a designation of personality pathology or disorder. Those of us who have taught undergraduates over the last several decades certainly recognize that students now seem somewhat more self-focused than two decades ago, but that does not necessarily translate into NPD. Aside from the issue of whether we are witnessing an increase in NPD and narcissism in Western society, there is another issue. Are our current approaches to the measurement of NPD sufficient? Here, I highlight two alternative assessment approaches that may be especially useful in the assessment of NPD (and other PDs as well). First, an underutilized assessment method in personality disorders is that of peer assessment (Oltmanns & Turkheimer, 2009). If pathological personality traits are primarily ego-syntonic (as Paris [2014] suggests is the case in NPD), then it seems less likely that individuals will accurately self-report either high, maladaptive levels of the traits or problems associated with the traits. For example, Carlson, Vazire, and Oltmanns (2011) recently reported on three studies aimed at evaluating how aware individuals with narcissism are regarding negative aspects of their personality and reputation. Although these studies did not include patients with NPD, the findings seem relevant. First, those high in narcissism do view themselves positively, but they also seem to appreciate that others do not see them as positively as they see themselves. However, despite the awareness of this more negative external evaluation from others, results were consistent with the view that those with narcissism view their own narcissistic traits as positive. Second, individuals with narcissism appear to make a good first impression initially that then deteriorates over time. Overall, these findings suggest that a multipronged approach to the assessment of NPD is needed—self-reports alone do not capture the full picture and longitudinal data may be necessary to assess relationship disruptions and dissolutions.
Paris (2014, pp. 220 –226) provides an interesting and provocative overview of the diagnosis, etiology, and treatment of narcissistic personality disorder (NPD). In particular, his article focuses on the potential sociocultural influences on the prevalence of this disorder, recent arguments that narcissism in general and NPD in particular are on the rise because of cultural influences, and the possibility that standard forms of psychotherapy may actually serve to maintain or even exacerbate NPD. As Paris (2014) notes, NPD has recently received more attention from the mental health community for two reasons. First, many papers, articles, and books suggesting that narcissism and NPD are increasing in prevalence at alarming rates have been published over the last 10 years. Second, when the initial DSM-5 proposal to delete NPD from the nomenclature appeared, many scholars, researchers, and clinicians came to this construct’s defense, bringing NPD back into the limelight. In this commentary, I focus on several assessment issues for narcissism, as well as NPD in particular. One issue that Paris (2014) highlighted is the apparent disagreement about the prevalence of NPD. On the one hand, we have scholars talking about narcissism (and NPD by extension) reaching epidemic proportions; on the other hand, there is little evidence from large clinical or nonclinical samples, assessed via structured interview, that the prevalence of NPD is high (or higher than most PDs). So, what is the actual prevalence of NPD? Almost all large, epidemiological studies of NPD suggest that the prevalence of this disorder is about 1% (Trull, Jahng, Tomko, Wood, & Sher, 2010). It is also worth noting that even studies of clinical samples do not report particularly high rates of NPD (e.g., less than 3%; Zimmerman, Rothschild, & Chelminski, 2005). Adopting a trait perspective, there does not seem to be sufficiently strong evidence to conclude there has been a major rise in rates of narcissism or narcissistic traits either. NPD is related primarily to low levels of agreeableness (i.e., antagonism) and higher levels of extraversion (Samuel & Widiger, 2008; Saulsman & Page, 2004). Concerning lower-order personality traits, NPD is significantly associated with lower levels of trust, straightforwardness, altruism, compliance, and modesty; NPD is also significantly associated with higher levels of angry hostility (Samuel & Widiger, 2008). In the DSM-5 draft proposal, NPD is characterized by only two personality traits, grandiosity and attention-seeking. Although levels of personality traits do change over the life span,
Correspondence concerning this article should be addressed to Timothy J. Trull, Department of Psychological Sciences, 210 McAlester Hall, University of Missouri, Columbia, MO 65211. E-mail: [email protected] 230
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
COMMENTARY
Another approach that can shed light on the interpersonal behavior of those with narcissism is the use of naturalistic observation. For example, the Electronically Activated Recorder (EAR; Mehl et al., 2001) captures ambient sounds in an individual’s natural environment using a small computer or mobile phone as the recording device. This ambulatory assessment method has already been used to study psychopathology related to depression and borderline personality disorder (e.g., Tomko et al., in press). The EAR can be worn or carried in daily life unobtrusively, and the recordings can be coded for activities (working, talking), environment (in car, at a restaurant), interpersonal context (with others or alone), affect, and word use, for example. What might EAR recordings tell us about NPD in daily life? Holtzman, Vazire, and Mehl (2010) recently reported EAR findings in a sample of undergraduates, some of whom scored high on narcissistic traits. Positive correlations were found between narcissistic traits and extraverted/positive acts (e.g., talking, being in a group, socializing, and using words related to friendship), disagreeable acts (e.g., arguing, using swear words, using anger words), and use of sexual language. These findings indicate that narcissistic traits are associated with both positive and negative acts, perhaps reflecting the difficulty clinical researchers and clinicians experience in identifying the problems and impairment one might expect to be associated with narcissism and NPD. In closing, I want to highlight some implications for the clinical assessment of NPD. First, it seems clear that traditional clinical assessment approaches for NPD are inadequate. The self-reports of those with NPD do not tell the whole story, and those with NPD may be unable to accurately label their interpersonal impact on others as negative or dysfunctional. Yes, they recognize that others may not hold them in as high regard as they hold themselves, but that does not translate into being aware of the negative impact of their own behavior. In addition, cross-sectional assessments will not be able to adequately capture the interpersonal pattern associated with NPD: initially, the friendly extravert that is sought out by others; later, the relationship partner who is too self-focused and perhaps disparaging; and, finally, the person who ends the relationship or causes the previous “friend” to feel used or neglected. There is clearly a benefit to gathering data from peers, family members, or significant others who know the person well over a period of time. Second, new assessment methods that sample the everyday life of individuals may be particularly well-suited to reveal aspects of NPD that cannot be captured adequately by traditional clinical questionnaires and interviews. The dysfunction associated with NPD is manifested in everyday life, and neither lab studies nor cross-sectional self-reports are able to reliably capture what happens in the real world. Another advantage of ambulatory assessment methods is that individuals choose what they do in daily life and with whom they spend time, enhancing ecological validity. Furthermore, ambulatory assessment avoids the reliance on reports of what individuals remember retrospectively or what they believe they are like. Therefore, ambulatory assessment holds
231
great promise in the assessment of the real-world correlates of narcissistic traits and NPD.
References 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. Carlson, E. N., Vazire, S., & Oltmanns, T. F. (2011). You probably think this paper’s about you: Narcissists’ perceptions of their personality and reputation. Journal of Personality and Social Psychology, 101, 185–201. Holtzman, N. S., Vazire, S., & Mehl, M. R. (2010). Sounds like a narcissist: Behavioral manifestations of narcissism in daily life. Journal of Research in Personality, 44, 478 – 484. Mehl, M. R., Pennebaker, J. W., Crow, D. M., Dabbs, J., & Price, J. H. (2001). The Electronically Activated Recorder (EAR): A device for sampling naturalistic daily activities and conversations. Behavior Research Methods Instruments & Computers, 33, 517–523. Oltmanns, T. F., & Turkheimer, E. (2009). Person perception and personality pathology. Current Directions in Psychological Science, 18, 32–36. Paris, J. (2014). Modernity and narcissistic personality disorder. Personality Disorders: Theory, Research, and Treatment, 5, 220 –226. doi: 10.1037/a0028580 Raskin, R., & Terry, H. (1988). A principal-components analysis of the Narcissistic Personality Inventory and further evidence of its construct validity. Journal of Personality and Social Psychology, 54, 890 –902. Rosenthal, S. A., Montoya, R. M., Ridings, L. E., Rieck, S. M., & Hooley, J. M. (2011). Further evidence of the Narcissistic Personality Inventory’s validity problems: A meta-analytic investigation: Response to Miller, Maples, and Campbell. Journal of Research in Personality, 45, 408 – 416. Samuel, D. B., & Widiger, T. A. (2008). A meta-analytic review of the relationships between the five-factor model and DSM–VI–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. Tomko, R. L., Brown, W. C., Tragesser, S. L., Wood, P. K., Mehl, M. R., & Trull, T. J. (in press). Social Context of Anger in Borderline Personality Disorder and Depressive Disorders: Findings from a Naturalistic Observation Study. Journal of Personality Disorders. 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, 412– 426. Twenge, J. M. (2001). Birth cohort changes in extraversion: A crosstemporal meta-analysis, 1966 –1993. Personality and Individual Differences, 30, 735–748. Twenge, J. M., & Foster, J. D. (2010). Birth cohort increases in narcissistic personality traits among American college students, 1982–2009. Social Psychological and Personality Science, 1, 99 –106. Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of DSM–IV personality disorders in psychiatric outpatients. American Journal of Psychiatry, 162, 1911–1918.
