历史回顾：自恋与自恋性人格 A HISTORICAL REVIEW OF NARCISSISM AND NARCISSISTIC PERSONALITY

翻译成中文

第一章

历史回顾：自恋与自恋性人格

Kenneth N. Levy, William D. Ellison, 和 Joseph S. Reynoso

过去几十年里，自恋这个概念从学术界到媒体都受到了极大的关注，这实在是非常具有讽刺意味的。这样的关注会让源自希腊神话中的Narcissus（自恋狂）感到非常自豪。Narcissus的传说最早是在公元前七或八世纪作为荷马诗篇歌唱的（Hamilton, 1942），并在Ovid的《变形记》（Metamorphoses，8/1958）中得到普及。从一个相对不为人知的起点，它已经成为我们这个时代的原型神话之一，诸如“自恋文化”、"我"一代（Lasch, 1979; Wolfe, 1976, 1977）和最近的“权利时代”（Twenge & Campbell, 2009）这样的词语也因此而生。在本章中，我们将提供一个关于自恋概念及其从神话到当前精神病学命名体系中官方人格障碍的历史回顾。

术语与来源

关于Narcissus故事最为人知的古典描述来自罗马诗人Ovid，他在公元8年将其收录在他的故事集《变形记》中。简而言之，Ovid对这个希腊罗马寓言的描述是，Narcissus是一个因其美貌而受到所有人崇拜的年轻人（Bulfinch, 1855; Hamilton, 1942）。他拒绝了许多崇拜他的人的关注，包括一名仅能重复对她说过的最后一个音节的女神Echo，这是因为她受到了宙斯的妻子赫拉的惩罚。被Narcissus忽视后，Echo最终消瘦至只剩下她重复的声音。Narcissus的残忍最终受到了复仇女神Nemesis的惩罚，她应了另一个被他轻视的人的祈祷。她使他陷入无法回应的爱中，就像他对许多他拒绝的人所做的那样（在Ovid的描述中，包括男性和女性）。Narcissus在一池水中瞥见了自己的倒影，被自己反映出的美貌所震惊。他越是凝视自己，就越是迷恋，但像许多其他未能得到他回应的人一样，他在无效的爱中感到空虚。他一直凝视着自己的倒影，直到绝望地死去，Echo也在他身边，重复着他最后的垂死之言。

Ovid的版本无疑是最为人知和最详细的，并且包含了与后来关于自恋的发展有关的元素。他的版本从一个预言开始，由盲先知Tiresias预言Narcissus将会有一个很长的寿命，“si se non noverit”——也就是，除非他了解自己。正如许多学者所评论的，这一点似乎颠覆了古希腊（和精神分析）关于自我认知的理想（例如，Davies, 1989），并预示了几位现代精神分析家对于治疗病理性自恋的修改建议（例如，Kohut & Wolf, 1978）。关于Narcissus的神话存在其他版本，它们也引入了与自恋结构有关的主题。例如，一个更早的文本来自一组古希腊文件的集合，这些文件来自埃及，归因于Parthenius of Nicaea，一个公元前一世纪的希腊诗人（Hutchinson, 2006）。这个更早的版本值得注意，因为它与Conon的叙述（Graves, 1954）一起表明，Narcissus并没有简单地消瘦至死，而是自杀了，要么是因为恋爱，要么是因为对他拒绝的许多追求者的内疚。这一细节预示了精神分析的观点，即自恋可以与强烈的绝望和自我谴责共存（King & Apter, 1996; Reich, 1960）。

根据古典描述，最早研究自恋作为一种人格特质的理论家主要是在其在人类性行为中的表现方面进行研究的，尽管他们没有对其正常性或病理性给出明确的看法。英国性学家-医生Havelock Ellis是第一个用Narcissus（纳西瑟斯）神话来描述一种自恋性的性状况的人。在这些“纳西瑟斯式”的案例中，这种倾向是“性情感被吸收，甚至完全消失，在自我赞美中”（1898年）。Ellis对这个神话人物的引用导致了性学家Paul Näcke（1899年）将这个概念（Narcismus）应用到他观察到的自恋行为中，即自我被当作一个性对象对待。虽然在19世纪精神病学的背景下，过度关注身体被认为是一种变态，但Ellis后来指出，这种“心理态度”可以被认为是正常范围内的（1927年）。

精神分析师是下一组详细阐述自恋概念的人，最早的引用可追溯到Isidor Sadger（1908年，1910年）。Sadger区分了正常程度的自我主义和自爱（在儿童和一些成年人中表现出来）与涉及过度评价和过度投资于自己身体的更极端和病理形式。他认为成熟的性爱必须经过一个自我爱的阶段，尽管不会固定或过分专注于它。1911年，Otto Rank写了第一篇完全关于自恋的精神分析论文，该论文是基于他对女性患者的研究。在这篇和后续的工作中，Rank（1914/1971年）负责了许多重要的早期观点，包括他对自恋作为一种虚荣和自我赞美的理解，这不仅仅是性的，而且也有防御功能，并与后来由Kohut讨论的双胞胎和镜像经验有关。也就是说，自恋个体倾向于需要其他人来感觉连接，并沉浸在强大和有力的人的光环中。

正如Freud在他1914年关于自恋的论文中所承认的，Rank帮助将自恋置于正常人类发展的范畴中。Freud自己对自恋的看法变化很大，从一种性变态和原始思维的品质到“一种对象选择，一种对象关系，和自尊”（Pulver，1970年）。在他关于这个主题的著作中，自恋既可以是心理-性发展的一个普遍阶段，也可以是自我保护本能的一个组成部分，以及一个病理性人格的标志。他的理论是基于对精神病患者、幼儿、临床患者材料以及性爱关系的观察。Freud首次提到自恋是在1910年加入到“关于性理论的三篇论文”（1905/1957年）的后来的脚注中，并在论文“关于自恋：一个介绍”（1914/1957年）中最全面地写了这个主题。在这篇论文中，Freud注意到了自恋中始终排除任何可能减少自我感觉的信息或感情的动态特点。从发展的角度来看，他还讨论了从对自我的正常但相对专注的关注到成熟的关联性的转变。在所有这些早期论文中，自恋被描述为一个与当代特质理论家描述正常特质的病理表现方式相当相似的维度心理状态（尽管Rank和Freud将自恋视为动态的——也就是说，他们将自大视为一种对感觉不重要的防御）。在所有这些著作中，自恋被概念化为一个过程或状态，而不是一种人格类型或障碍。早期关于病理性自恋发展的推测将其与嫉妒密切相关。例如，Abraham（1919/1979年）将自恋与嫉妒以及对爱对象的轻蔑或敌意态度相关联，这可能是由于个体过去在养育方面的失望。Ernest Jones（1913/1974年）在一篇关于“上帝情结”的论文中描述并概念化了自恋作为一种病理性的性格特质。那些有上帝情结的人被认为是冷漠的、不可接近的、自我赞美的、自我重要的、过度自信的、喜好展示的，并且有全能和全知的幻想。Jones对个体对现实和全能感观的“混合”或混淆作了早期的观察，作为一种防御。更晚些时候，Reich（1960年）建议自恋是一种病理性的自尊调节形式，其中自我膨胀和侵略性被用来保护自己的自我概念。

自恋作为一种人格或性格风格和障碍

自恋人格或性格的概念最早由Wälder（1925年）明确提出。Wälder描述自恋人格的个体为居高临下、感觉高人一等、专注于自己和仰慕，以及明显缺乏同情心，这在他们以纯粹的物理愉悦为基础的性行为中尤为明显，而不是与情感亲密结合在一起。尽管弗洛伊德在他1914年的论文中没有讨论自恋作为一种人格类型，但在1931年，继Wälder之后，他描述了自恋性欲望或性格类型。在这篇论文中，他将自恋个体描述为主要关注自我保护的人。这些个体非常独立、外向、不容易被吓倒、侵略性强，且无法在亲密的关系中表达爱或承诺。尽管有这些问题，弗洛伊德指出，这些个体经常吸引人们的仰慕和关注，并且经常处于领导地位。重要的是，在这篇论文中，弗洛伊德建立了自恋和侵略性之间的联系。

精神分析学家威廉·赖希（Wilhelm Reich，1933/1949年）在提出阳具-自恋性格时，对弗洛伊德的观察进行了拓展，其特点是自信、傲慢、高傲、冷漠和侵略性。重要的是，赖希通过阐述两者之间的动态关系，对弗洛伊德关于自恋和侵略性之间联系的观察进行了拓展。赖希指出，自恋个体在情感上受到伤害、受伤或受威胁时，会以冷漠的蔑视、坏情绪或公开的侵略性做出反应。顾名思义，赖希认为自恋与男性气质的观念有关，更常见于男性，并认为自恋个体过度认同阳具。自恋与男性之间的联系最早可以在阿尔弗雷德·阿德勒（Alfred Adler，1910/1978年）的男性抗议概念中看到，其意味着想要变得强大、有力和特权，目的是提高自尊。

1939年，卡伦·霍妮（Karen Horney）基于自恋是一种性格特质的观点，提出了自恋的不同表现形式（例如，侵略性-扩张型、完美主义者和傲慢报复型）。此外，霍妮将健康的自尊与病理性自恋区分开来，并建议将自恋这个术语限制于不切实际的自我膨胀。通过自我膨胀，霍妮的意思是，当没有做这样的事情的基础时，自恋者会爱、仰慕和珍视自己。这是一个重要的贡献，可以在后来Kernberg关于病理性自大观念的著作中看到。尽管霍妮在自恋的许多方面上都同意弗洛伊德，但她与他有所不同的是，她提出自恋者并不是因为过多的自爱而受苦，而是无法爱任何人，包括他们自己真正的方面。霍妮的观念与病理性自恋中的防御性自大性质是一致的。

这种防御性观念也由温尼科特（Winnicott，1965年）明确提出，他区分了真实的自我和虚假的自我概念。温尼科特提出，自恋个体会防御性地认同一个自大的虚假自我。温尼科特的观点与Kernberg和霍妮的观点相似，即投资于虚假的自我与投资于自大的病理性自我表征相似。温尼科特对自恋的概念也与Kohut相似，因为她强调了其病因中照顾者失败的作用，以及治疗中持有环境的作用，以便让真实的自我浮现。

基于自恋作为一种防御感觉脆弱的观点，安妮·赖希（Annie Reich，1960年）提出，自恋个体因为早期反复的创伤性经历而无法调节他们的自尊。他们然后退缩到一个自我保护的、自大的幻想世界中，其中自我不是软弱和无力的，而是安全的、强大的，并高人一等。赖希的工作也很重要，因为她是第一个强调自恋者中“自尊的重复和剧烈波动”（第224页）的人。她指出，自恋者对模棱两可、平庸或失败的容忍度很低，他们将自己看作要么是完美的，要么是完全的失败。这种缺乏整合导致他们在自大的高度和绝望和抑郁的深渊之间戏剧性地转换。

1961年，Nemiah明确地描述了自恋不仅作为一种人格类型，而且作为一种障碍，当他创造了自恋性格障碍这个术语时。1967年，Kernberg在阐述边缘性格组织的一部分时，提出了他所称之为自恋性格结构的临床描述。在后来的论文中，Kernberg（1970年）提供了这种性格结构的临床特点的明确描述，提出了基于容易观察到的行为的诊断，并区分了正常和病理性自恋。然而，是Kohut（1968年）后来引入了自恋性格障碍这个术语。

对自恋的兴趣增加

Kernberg 和 Kohut 关于自恋的著作部分地是对这些病人日益得到临床认可的反应。他们的论文激发了全球对自恋本质以及最佳概念化和治疗方式的巨大兴趣。

在 Kernberg（1967、1970、1975、1992）的观点中，自恋是由于父母的拒绝、贬低和情感上无效的环境而发展起来的，在这种环境中，父母对孩子的投资不一致或经常与孩子互动以满足自己的需求。例如，有时父母可能对孩子冷淡、轻视和忽视，然后在其他时候，当符合父母的需求时，又会变得关注甚至侵入性强。这种父母贬低假说认为，由于冷漠和拒绝的父母，孩子会防御性地撤退并形成一个病理性的自大自我表象。这种自我表象结合了真实孩子、孩子想成为的幻想方面以及理想的、充满爱心的父母的幻想方面，作为一个内在的避难所，以抵御早期环境作为严酷和剥夺的经验。孩子的负面自我表象被否认和不被整合进自大的表象中，这是自恋者操作的代理机构所在。这种分裂的不可接受的自我表象可以在自恋者经历的空虚感、对钦佩和刺激的持续渴望以及耻辱中看到（Akhtar & Thomson，1982）。

Kohut（1971、1977）认为自恋是一种正常发展过程出错的结果。Kohut认为，病理性自恋是由于由于拒绝或冷漠而无法理想化父母而产生的。对于 Kohut，儿时的自大是正常的，并且可以理解为孩子试图识别并成为他理想化的父母形象的一个过程。孩子希望通过承担他或她在别人身上钦佩的能力和力量的属性来得到钦佩。在正常发展中，这个早期的自大自我最终有助于一个整合的、充满活力的自我感觉的形成，具有现实的抱负和目标。然而，如果这个自大的自我没有得到适当的调节，接下来就是这个自大自我未能整合进个人的整体人格中。根据 Kohut，作为一个成年人，一个有自恋的人以“原始”的方式与别人建立关系，这适合于处于恰当自我发展的早期阶段的人。其他人被视为自我（Kohut 的术语是自我客体）的延伸，并依赖他们来调节自己的自尊和关于稳定身份的焦虑。因为自恋者无法充分应对日常生活及其情感相关的正常波动，其他人无意中被降级为为他们提供内部调节的角色（通过无条件的支持、钦佩和全面的共情调和），就像一个父母为一个年幼的孩子提供内部调节一样。

尽管 Kohut 和 Kernberg 在自恋的病因和治疗方面有分歧，但他们在自恋的现象学或表达方面，特别是对于健康范围内的患者，有很多一致的看法。这两位作者在塑造自恋人格障碍的概念方面都有很大影响，不仅在精神分析学家中，而且在当代人格研究者和理论家（Baumeister、Bushman 和 Campbell，2000；Campbell，1999；Dickinson 和 Pincus，2003；Emmons，1981、1984、1987、1989；John 和 Robins，1994；Raskin 和 Hall，1979；Raskin、Novacek 和 Hogan，1991；Raskin 和 Terry，1988；Robins 和 John，1997；Rose，2002；Wink，1991、1992a、1992b）以及美国精神病学协会的诊断和统计手册（见 Frances，1980，以及 Millon，1997，关于 DSM 对自恋人格障碍概念发展的讨论）中都如此。

这些临床和人格心理学的趋势也与批判社会理论（Adorno，1967、1968；Blatt，1983；Horkheimer，1936；Horkheimer 和 Adorno，1944；Lasch，1979；Marcuse，1955；Nelson，1977；Stern，1980；Westen，1985；Wolfe，1977）中的趋势相平行。20世纪看到了各个领域的作家使用 Narcissus 神话和主要是精神分析派导出的一种自恋状况或状态来描述个体和社会现象。法兰克福学派，特别是社会学家-哲学家 Theodor Adorno（1968）使用了自恋的概念来描述现代集体自我的弱点在面对不断变化的经济因素和工业化结构面前的防御性管理。1976年，美国记者和作家 Tom Wolfe 将 1970 年代称为美国的“我”十年，并推测经济繁荣导致了个体庆祝和自我关注的过度和奢侈的爆发，远离了以前的联系价值观。1979年，美国历史学家和社会评论家 Christopher Lasch 出版了《自恋的文化》。在其中，Lasch 描述了美国文化的现状为一种自恋式的权利个人主义和极端的堕落。通过分析全国和个体趋势，Lasch 认为，一种社会结构已经在几十年内发展起来，这种结构导致了一种集体和个体性格的形成，该性格是围绕补偿性的自我关注而组织的，并远离了美国传统的竞争理想。最近，Twenge 和 Campbell（2009）根据汇总的研究结果和全国趋势的观察诊断了一场自恋的社会性流行病。他们注意到，越来越多的研究表明，自恋和自我膨胀随着时间的推移而增加。对美国大学生从 1980 年代到现在的自恋人格问卷（NPI；Raskin 和 Hall，1979、1981；Raskin 和 Terry，1988）的研究发现自恋率呈上升趋势。在 85 个美国大学生样本（n = 16,475）中，NPI 分数增加了 0.33 个标准差（近三分之二的最近的大学生得分高于 1979年到 1985年学生的平均分）。在文化权利、物质主义、虚荣和反社会行为不断增加的根本原因上，Twenge 和 Campbell 关注诸如家庭角色和做法的变化以及美国价值观的转变，这些价值观优先考虑自我表达和自我钦佩。

诊断与统计手册与自恋型人格障碍

1935年，美国精神病学协会（APA）根据Kraepelin（1899，1913）的有影响力的教科书开发了一个诊断系统。APA将这个系统提交给美国医学协会，以包含在其《疾病的标准分类术语》中；然而，该系统很快就暴露出一些弱点（例如，该系统是为住院病人开发的，对于急性病症不太相关，而且它没有整合当时在美国流行的精神分析理论）。由于这些问题，军事医院和退伍军人管理局医院各自发展了自己的分类系统。这些系统经常不一致，并造成了沟通困难。1951年，美国公共卫生服务委托来自美国精神病学协会的代表，对美国使用的诊断系统进行标准化，这导致了1953年出版的DSM-I。DSM的第一版是一个基于Adolf Meyer的发展心理生物观点描述各种诊断类别的词汇表。DSM-I描述了108种不同的障碍。其中许多障碍被描述为对可能导致情感问题的环境条件的反应。DSM的第二版（1968）基于《国际疾病分类》（ICD-9）的第8次修订版的精神病分类。DSM-II在神经性障碍和精神病性障碍之间进行了区分，并指定了182种不同的障碍。除了神经症的描述（这在很大程度上受到了心理动力学思想的影响），DSM-II没有为理解非有机性精神障碍提供理论框架。DSM-II中各种精神病障碍的描述是基于一组专家委员会和其顾问（Widiger, Frances, Pincus, Davis, & First, 1991）的最佳临床判断。在DSM-I或II中，自恋或自恋型人格障碍都不是官方诊断。

自恋型人格障碍（NPD）首次在《精神障碍的诊断与统计手册-III》（DSM-III，1980）中被引入官方诊断系统，这要归功于临床医生对该概念的广泛使用，以及Kernberg、Kohut和Millon的著作，以及一系列心理学研究中将自恋作为一种人格因素的识别（参见本卷第2章，关于从DSM-III到DSM-IV-R的自恋型人格障碍诊断的历史演变）。尽管从DSM-III到–III-R和IV的NPD标准的许多变化都是由于对实证研究的增加关注而产生的，Cain、Pincus和Ansell（2008）注意到，这也导致了许多基础性的脆弱主题被剔除。其他人也强调了这一观点（Cooper, 2000; Levy, Reynoso, Wasserman, & Clarkin, 2007）。此外，该障碍在心理状态或行为方面的动态变化也被剔除了。最后，有人可能会争辩说，标准变化的某些方面代表了一种关注，即将NPD与其他障碍区分开来，并减少合并症，但这是以损害该障碍真正现象学本质为代价的。

子类型

DSM-III-R和DSM-IV的变化导致了一系列批评，认为DSM未能捕捉到预期的临床现象（Cain等，2008年；Cooper，2000年；Cooper & Ronningstam，1992年；Gabbard，1989年；Gunderson, Ronningstam, & Smith，1991年；Levy等，2007年）。这些作者指出，DSM标准集的变化越来越强调自恋的外显和浮夸方面，同时淡化和消除了对自恋更脆弱方面的参考。许多临床和学术作者，如Cooper（1981）、Akhtar和Thomson（1982）、Gabbard（1989）和Wink（1991），都建议NPD有两个子类型：一个是外显型，也称为浮夸型、无觉型、任性型、展示型、厚脸皮或阳具型；另一个是隐性型，也称为脆弱型、高度敏感型、壁橱型或薄脸皮型（Bateman，1998年；Britton，2000年；Gabbard，1989年；Masterson，1981年；Rosenfeld，1987年）。外显型以自大、寻求关注、权威、傲慢和很少可观察到的焦虑为特点。这些人在不顾及他人需求的情况下，可以在社交场合中表现得很迷人，人际关系上是剥削性的，并且嫉妒。相反，隐性型对他人的评价高度敏感，抑制，明显受抑，外表谦逊。Gabbard（1989年）描述这些人为害羞和“安静的自大”，具有“对轻微之事的极端敏感性”，这“导致他们勤勉地避免聚光灯”（第527页）。两种类型都非常自恋，并对自己抱有不切实际的自大期望。这种外显-隐性的区别至少在六项使用因子分析和相关方法的研究中得到了实证支持（Dickinson & Pincus，2003年；Hendin & Cheek，1997年；Hibbard & Bunce，1995年；Rathvon & Holmstrom，1996年；Rose，2002年；Wink，1992a，1992b）。

Kernberg指出，自恋的外显和隐性表达可能是该障碍的不同临床表现，一些特质是外显的，而其他特质是隐性的。Kernberg认为，自恋个体持有自我矛盾的观点，这些观点在外显和隐性症状的临床表达之间摇摆不定。因此，外显自恋的个体最常表现为自大、展示和权威。然而，在面对失败或损失时，这些人会变得抑郁、耗尽和感到痛苦地自卑。隐性自恋的个体通常表现为害羞、胆小和抑制，但在更接近的接触中，会透露出展示和自大的幻想。

最后，Kernberg区分了一种他称之为“恶性自恋”的NPD类型。这些患者的特点是典型的NPD症状；然而，他们还表现出反社会行为，倾向于偏执特征，并对他们对他人的攻击和虐待感到愉悦。Kernberg（1992年）认为，这些患者有很高的自杀风险，尽管没有抑郁症。Kernberg建议，这些患者的自杀行为代表对他人的虐待控制，对被贬低的世界的摈弃，或对死亡的掌控展示。尽管Kernberg的描述非常丰富，我们找不到关于恶性自恋的直接研究。区分恶性自恋和常规NPD（以及反社会、偏执和边缘人格障碍）并显示符合Kernberg对恶性自恋标准的患者面临Kernberg临床描述的那种困难将是重要的。

来自社会-人格心理学的贡献

虽然社会和人格心理学家的评估和因子分析研究是NPD被纳入DSM-III的关键因素（Ashby等，1979年；Block，1971年；Cattell等，1964年；Frances，1980年；Harder，1979年；Leary，1957年；Murray，1938年；Pepper & Strong，1958年；Raskin & Hall，1979年；Serkownek，1975年），但现在正是这个领域的最新研究在影响有关自恋的理论。其中一些工作证实了过去的临床观察和理论，例如将自恋与羞耻（Gramzow & Tangney，1992年）、受害者身份的认知（McCullough, Emmons, Kilpatric, & Mooney，2003年）以及攻击性（Pincus等，2009年）联系起来。

其他社会心理学研究正在挑战长期以来的假设。虽然这些工作需要得到确认，但一些研究人员发现，自恋是对低自尊的一种防御性掩饰的观点并没有得到证据支持（Baumeister等，2000年）。这些发现与自恋与较高自尊相关的发现相结合，导致一些人认为自恋更像是对高自尊的一种依赖，而不是对低自尊的一种防御（Baumeister & Vohs，2000年）。与这一结论一致的是，使用隐性联想测验（IAT；Greenwald, McGhee, & Schwartz，1998年）的创造性研究表明，自恋与隐性自尊有关（Campbell, Bosson, Goheen, Lakey & Kernis，2007年；Jordan, Spencer, Zanna, Hoshino-Browne, & Correll，2003年；Zeigler-Hill，2006年）。

总结和结论

虽然其在历史上的地位是稳固的，但随着DSM-5的即将到来，自恋和NPD（自恋性人格障碍）的未来是不确定的。当前DSM-5的概念并没有将NPD包括在五大主要人格障碍类型之中。然而，NPD的各个方面被包括在拟议模型的其余三个组成部分中（人格功能水平、一般人格功能障碍和人格特质）。因此，人格障碍工作组建议，通过使用这种混合模型可以捕捉到自恋性功能。工作组已经提议，新模型应允许对自恋进行多维度评估，从而提供一个更为细致的描述。当然，DSM-5中自恋或NPD的最终概念化还需要来自现场试验和科学界内部讨论的更多数据，而且无论其在DSM-5中如何被包括，对这一概念的研究都将继续。有一点是肯定的：尽管自恋有着丰富的历史，对理解临床现象有着广泛的贡献，并且在概念化社会趋势方面有着广泛的影响，但它只是相对近期才开始得到应有的关注。NPD被纳入DSM-III导致了研究的激增，但数据表明这种兴趣已经趋于平稳（Konrath，2008年）。尽管有这一发现，来自临床心理学和精神病学以及社会-人格心理学的研究结果表明，更加密集地关注自恋是有必要的。

Chapter 1

A HISTORICAL REVIEW OF NARCISSISM AND NARCISSISTIC PERSONALITY

Kenneth N. Levy, William D. Ellison, and Joseph S. Reynoso

It is greatly ironic that the concept of narcissism has been the subject of so much attention from academia to the media and has captured the public’s mind over the past few decades. This attention would make Narcissus, the subject of the Greek myth from which the term narcissism is derived, very proud indeed. The legend of Narcissus, originally sung as Homeric hymns in the seventh or eighth century BC (Hamilton, 1942) and popularized in Ovid’s Metamorphoses (8/1958), has risen from a relatively obscure beginning to become one of the prototypical myths of our times, with the coining of such terms as culture of narcissism, me generation (Lasch, 1979; Wolfe, 1976, 1977), and more recently the age of entitlement (Twenge & Campbell, 2009). In this chapter we provide a historical review of the concept of narcissism and its evolution from myth to an ofﬁcial personality disorder in the current psychiatric nomenclature.

TERM AND DERIVATION

The best-known classical account of the Narcissus 1 story comes from the Roman poet Ovid, who in 8 C.E. included it in his collection of stories, Metamorphoses. To paraphrase Ovid’s rendering of the Greco-Roman fable, Narcissus was a youth admired by all for his beauty (Bulﬁnch, 1855; Hamilton, 1942). He rejected the attention of the many who adored him, including the nymph Echo, who by punishment of Zeus’ wife Hera, could only repeat the last syllable of speech said to her. Ignored by Narcissus, Echo eventually wasted away until all that remained of her was her repeating voice. Narcissus’ cruelty was eventually punished when an avenging goddess, Nemesis, answered the prayer of another he had scorned. She condemned him to unrequited love, just as he had done to the many he had spurned (both males and females, in Ovid’s telling). Catching a glimpse of himself in a pool of water, Narcissus was paralyzed by the beauty of his own reﬂected image. The more he gazed at himself, the more infatuated he became, but like the many others whose affection he did not return, he was left empty in his futile love. He remained gazing at his own reﬂection in despair until death, with Echo by his side to repeat to him his last dying words.

Ovid’s version of the myth is undoubtedly the best-known and most detailed and contains elements that resonate with later developments on narcissism. His version begins with a prophecy by the blind seer Tiresias that Narcissus will have a long life “si se non noverit”—that is, unless he knows himself. As many scholars have commented, this remark seems to subvert the classical Greek (and psychoanalytic) ideal of self-knowledge (e.g., Davies, 1989) and anticipates several modern psychoanalysts’ arguments for a modiﬁed treatment for pathological

1 Narcissus is a ﬂower whose name derives from the Greek word Narke or Narcotic, by virtue of its power to alleviate pain and suffering.

3 4

Narcissism and NPD: Constructs and Models

narcissism (e.g., Kohut & Wolf, 1978). Other versions of the Narcissus myth exist and themselves introduce themes that have relevance for the construct of narcissism. For example, an earlier text dealing with the myth from a collection of ancient Greek documents from Egypt is attributed to Parthenius of Nicaea, a Greek poet of the ﬁrst century B.C.E. (Hutchinson, 2006). This earlier version is notable because it joins a telling by Conon (Graves, 1954) in suggesting that Narcissus did not simply waste away but committed suicide, either from lovesickness or out of guilt over the many suitors he had spurned. This detail foreshadows the psychoanalytic insight that narcissism can coexist with intense despair and self-recrimination (King & Apter, 1996; Reich, 1960).

Following the classical account, the earliest theoreticians on narcissism as a personality characteristic studied it in relation to its manifestations in human sexuality, though without deﬁnitive thoughts on its normality or pathology. The British sexologist-physician Havelock Ellis was the ﬁrst to use the Narcissus myth to refer to an autoerotic sexual condition. The tendency in these “Narcissus-like” cases was “for the sexual emotions to be absorbed, and often entirely lost, in self-admiration” (1898). Ellis’ invocation of the mythical ﬁgure led the sexologist Paul Näcke (1899) to apply the concept (Narcismus2 ) to his observations of autoeroticism in which the self is treated as a sexual object. Though exaggerated bodily self-preoccupation was considered a perversion in the context of 19th-century psychiatry, Ellis later noted that this “psychological attitude” could be considered on the spectrum of normal (1927). Psychoanalysts were the next group to elaborate the concept of narcissism, with the earliest reference attributable to Isidor Sadger (1908, 1910). Sadger distinguished between a degree of egoism and self-love that was normal (evidenced in children and some adults) and the more extreme and pathological forms that involved overvaluation of and overinvestment in one’s own body. He saw mature sexual love as having to pass through a stage of self-love, though not becoming ﬁxed or preoccupied with it. In 1911, Otto Rank wrote the ﬁrst psychoanalytic paper exclusively on narcissism, which he based on his studies of his female patients. In this and subsequent work, Rank (1914/1971) is responsible for a number of signiﬁcant early ideas, including his understanding of narcissism as a vanity and self-admiration that was not exclusively sexual, but also served defensive functions and was linked to twin and mirror experiences later discussed by Kohut. That is, narcissistic individuals tend to need others to feel connected and to bask in the glow of strong and powerful people.

As Freud credits in his own paper on narcissism in 1914, Rank helped place narcissism in the realm of regular human development. Freud’s own views on narcissism varied a great deal, from a kind of sexual perversion and quality of primitive thinking to “a type of object choice, a mode of object relationship, and self-esteem” (Pulver, 1970). In his writings on the topic, narcissism can both be a universal stage of psycho-sexual development and a component of selfpreservatory instincts, as well as a marker of a pathological character. His theorizing is based on observations from psychotic patients, young children, clinical material from patients, as well as sexual love relationships. Freud ﬁrst mentions narcissism in a later footnote added in 1910 to “Three Essays on the Theory of Sexuality” (1905/1957), and most extensively writes on the topic in the paper “On Narcissism: An Introduction” (1914/1957). In this paper, Freud noted the dynamic characteristic in narcissism of consistently keeping out of awareness any information or feelings that would diminish one’s sense of self. In this paper he also discussed, from a developmental perspective, the movement from the normal but relatively exclusive focus on the self to mature relatedness. In all of these early papers, narcissism was described as a dimensional psychological state in much the same way that contemporary trait theorists describe pathological manifestations of normal traits (although Rank and Freud viewed narcissism as dynamic—that is, they saw grandiosity as a defense against feeling insigniﬁcant). In all these writings, narcissism was conceptualized as a process or state rather than a personality type or

2 Ellis gives Näcke credit for appending the “-ism” that led to the eventual term narcissism (1927). A Historical Review of Narcissism and Narcissistic Personality

disorder. 3 Relatedly, the earliest speculations on the development of pathological narcissism saw it as intimately linked with envy. For example, Abraham (1919/1979) associated narcissism with envy and a contemptuous or hostile attitude toward love objects, potentially due to past caregiving disappointments the individual had experienced. Ernest Jones (1913/1974) described and conceptualized narcissism as a pathological character trait in a paper on the “God Complex.” Those with a God Complex were seen as aloof, inaccessible, self-admiring, self-important, overconﬁdent, exhibitionistic and with fantasies of omnipotence and omniscience. Jones made early observations on the “blending” or confusion of the individual’s view of reality and omnipotence as a defense. Much later, Reich (1960) suggested that narcissism is a pathological form of self-esteem regulation whereby self-inﬂation and aggression are used to protect one’s self-concept.

NARCISSISM AS A PERSONALITY OR CHARACTER STYLE AND DISORDER

The concept of a narcissistic personality or character was ﬁrst articulated by Wälder (1925). Wälder described individuals with narcissistic personality as condescending, feeling superior to others, preoccupied with themselves and with admiration, and exhibiting a marked lack of empathy, often most apparent in their sexuality, which is based on purely physical pleasure rather than combined with emotional intimacy. Although Freud had not discussed narcissism as a personality type in his 1914 paper, in 1931, following Wälder, he described the narcissistic libidinal or character type. In this paper, he described the narcissistic individual as someone who was primarily focused on self-preservation. These individuals were highly independent, extraverted, not easily intimidated, aggressive, and unable to love or commit in close intimate relationships. Despite these issues, Freud noted that these individuals frequently attracted admiration and attention and often were in leadership roles. Importantly, it is in this paper that Freud made the connection between narcissism and aggression. The psychoanalyst Wilhelm Reich (1933/1949) expanded on Freud’s observations in proposing the phallic-narcissist character, characterized by self-conﬁdence, arrogance, haughtiness, coldness, and aggressiveness. Importantly, Reich expanded on Freud’s observation regarding the connection between narcissism and aggression by explicating the dynamic between the two. Reich noted that narcissistic individuals responded to being emotionally hurt, injured, or threatened with cold disdain, ill humor, or overt aggression. As suggested by the name, Reich viewed narcissism as linked to ideas of masculinity, more common in men, and felt that the narcissistic individual was overidentiﬁed with the phallus. The link between narcissism and masculinity could ﬁrst be seen in Alfred Adler’s (1910/1978) concept of masculine protest, which meant wanting to be strong, powerful, and privileged, the purpose of which was the enhancement of self-esteem.

In 1939, Karen Horney built on the idea that narcissism was a character trait by proposing divergent manifestations of narcissism (e.g., aggressive-expansive, perfectionist, and arrogantvindictive types). Additionally, Horney distinguished healthy self-esteem from pathological narcissism and suggested that the term narcissism be restricted to unrealistic self-inﬂation. By self-inﬂation, Horney meant that the narcissist loves, admires, and values himself when there is no foundation for doing so. This is an important contribution that can be seen in the later writings by Kernberg in his concept of pathological grandiosity. Although Horney agreed with Freud

3 In the course of his writings, Freud used the term narcissism to (a) describe a stage of normal infant development, (b) as a normal aspect of self-interests and self-esteem, (c) as a way of relating in interpersonal relationships, especially those characterized by choosing partners based on the other’s similarity to the self [over-investment of self] rather than real aspects of the other person, and (d) a way of relating to the environment characterized by a relative lack of interpersonal relations. These multiple uses of the term narcissism have resulted in signiﬁcant confusion about the concept, which persists even today. 6

Narcissism and NPD: Constructs and Models

on many aspects of narcissism, she diverged from him in her proposal that narcissists did not suffer from too much self-love but instead were unable to love anyone, including the genuine aspects of themselves. Horney’s conception is consistent with the defensive nature of pathological grandiosity in narcissism.

This defensive notion is also articulated by Winnicott (1965), who distinguished between a true self and a false self-conception. Winnicott proposed that narcissistic individuals defensively identify with a grandiose false self. Winnicott’s ideas are similar to Kernberg’s and Horney’s in that investment in the false self is similar to such an investment in a grandiose pathological self-representation. Winnicott’s conception of narcissism is also similar to Kohut in that she stresses caregiver failure in its etiology and the role of a holding environment in therapy in order to allow the true self to emerge.

Building on the idea of narcissism as a defense against feeling vulnerable, Annie Reich (1960) proposed that narcissistic individuals suffered from an inability to regulate their self-esteem as a result of repeated early traumatic experiences. They then retreat from others into a self-protective, grandiose fantasy world where the self is not weak and powerless but instead safe, strong, and superior to others. Reich’s work was also important because she was the ﬁrst to emphasize the “repetitive and violent oscillations of self-esteem” (p. 224) seen in narcissists. She noted that narcissists have little tolerance for ambiguity, mediocrity, or failure and that they see themselves as either perfect or a total failure. This lack of integration leads them to dramatically shift between the heights of grandiosity and the depths of despair and depression.

In 1961, Nemiah explicitly described narcissism not only as a personality type but as a disorder when he coined the term narcissistic character disorder. In 1967, Kernberg, as part of his articulation of borderline personality organization, presented a clinical description of what he called narcissistic personality structure. In a later paper, Kernberg (1970) provided explicit descriptions of the clinical characteristics of this character structure, suggested a diagnosis based on readily observable behavior, and distinguished between normal and pathological narcissism. However, it was Kohut (1968) who later introduced the term narcissistic personality disorder.

THE RISE OF INTEREST IN NARCISSISM

Kernberg’s and Kohut’s writings on narcissism were, in part, a reaction to increased clinical recognition of these patients. Their papers stimulated enormous worldwide interest about the nature of narcissism and how it should best be conceptualized and treated.

In Kernberg’s (1967, 1970, 1975, 1992) view, narcissism develops as a consequence of parental rejection, devaluation, and an emotionally invalidating environment in which parents are inconsistent in their investment in their children or often interact with their children to satisfy their own needs. For example, at times a parent may be cold, dismissive, and neglectful of a child, and then at other times, when it suits the parent’s needs, be attentive and even intrusive. This parental devaluation hypothesis states that because of cold and rejecting parents, the child defensively withdraws and forms a pathologically grandiose self-representation. This self-representation, which combines aspects of the real child, the fantasized aspects of what the child wants to be, and the fantasized aspects of an ideal, loving parent, serves as an internal refuge from the experience of the early environment as harsh and depriving. The negative self-representation of the child is disavowed and not integrated into the grandiose representation, which is the seat of agency from which the narcissist operates. This split-off unacceptable self-representation can be seen in the emptiness, chronic hunger for admiration and excitement, and shame that also characterize the narcissist’s experience (Akhtar & Thomson, 1982).

What Kernberg sees as defensive and compensatory in the establishment of the narcissist’s grandiose self-representation, Kohut (1971, 1977) views as a normal development process gone awry. Kohut sees pathological narcissism as resulting from failure to idealize the parents because A Historical Review of Narcissism and Narcissistic Personality

of rejection or indifference. For Kohut, childhood grandiosity is normal and can be understood as a process by which the child attempts to identify with and become like his idealized parental ﬁgures. The child hopes to be admired by taking on attributes of perceived competence and power that he or she admires in others. In normal development, this early grandiose self eventually contributes to an integrated, vibrant sense of self, complete with realistic ambitions and goals. However, if this grandiose self is not properly modulated, what follows is the failure of the grandiose self to be integrated into the person’s whole personality. According to Kohut, as an adult, a person with narcissism rigidly relates to others in “archaic” ways that beﬁt a person in the early stages of proper self-development. Others are taken as extensions of the self (Kohut’s term is selfobject) and are relied on to regulate one’s self-esteem and anxieties regarding a stable identity. Because narcissists are unable to sufﬁciently manage the normal ﬂuctuations of daily life and its affective correlates, other people are unwittingly relegated to roles of providing internal regulation for them (by way of unconditional support admiration and total empathic attunement), the same way a parent would provide internal regulation for a young child.

Although Kohut and Kernberg disagreed on the etiology and treatment of narcissism, they agreed on much of its phenomenology or expression, particularly for those patients in the healthier range. Both these authors have been inﬂuential in shaping the concept of narcissistic personality disorder, not only among psychoanalysts but also among contemporary personality researchers and theorists (Baumeister, Bushman, & Campbell, 2000; Campbell, 1999; Dickinson & Pincus, 2003; Emmons, 1981, 1984, 1987, 1989; John & Robins, 1994; Raskin & Hall, 1979; Raskin, Novacek, & Hogan, 1991; Raskin & Terry, 1988; Robins & John, 1997; Rose, 2002; Wink, 1991, 1992a, 1992b) and the Diagnostic and Statistical Manual of the American Psychiatric Association (see Frances, 1980, and Millon, 1997, for discussion of the development of DSM’s concept of narcissistic personality disorder).

These trends in clinical and personality psychology also paralleled trends in critical social theory (Adorno, 1967, 1968; Blatt, 1983; Horkheimer, 1936; Horkheimer & Adorno, 1944; Lasch, 1979; Marcuse, 1955; Nelson, 1977; Stern, 1980; Westen, 1985; Wolfe, 1977). The 20th century saw an upsurge in writers in various ﬁelds using the Narcissus myth and a predominantly psychoanalytic-derived conception of a narcissus-like condition or state to describe individual and social phenomena. The Frankfurt school, and in particular the sociologist-philosopher Theodor Adorno (1968), used the idea of narcissism to describe the defensive management of weakness in the modern collective ego in the face of changing economic factors and industrialized structures. In 1976, the American journalist and writer Tom Wolfe called the 1970s the Me Decade in America, and postulated that economic prosperity had led to an excessive and extravagant explosion of individual-celebration and self-focus and away from former values of connectedness. In 1979, the American historian and social critic Christopher Lasch published The Culture of Narcissism. In it, Lasch described the current state of American culture as one of narcissistically entitled individualism and extreme decadence. Analyzing national and individual trends, Lasch posited that a type of social structure had developed over decades, which was leading to the development of a collective and individual character that was organized around a compensatory self-preoccupation and away from traditional American competitive ideals. More recently, Twenge and Campbell (2009) diagnosed a societal epidemic of narcissism based on aggregated research ﬁndings and observations of national trends. They noted the accumulating research, which suggests increases in narcissism and ego inﬂation over time. Examination of the Narcissistic Personality Inventory (NPI; Raskin & Hall, 1979, 1981; Raskin & Terry, 1988) in American college students from the 1980s to present has found rising rates of narcissism. In 85 samples of American college students (n = 16,475) NPI scores have increased 0.33 standard deviations (almost two thirds of recent college students score above the mean of students from 1979 to 1985). At the root of the growing rise of cultural entitlement, materialism, vanity, and antisocial behaviors, Twenge and Campbell focus on factors such as changing familial roles and practices and a shift in American values privileging self-expression and self-admiration. 8

Narcissism and NPD: Constructs and Models

THE DIAGNOSTIC AND STATISTICAL MANUAL AND NARCISSISTIC PERSONALITY DISORDER

In 1935, the American Psychiatric Association developed a diagnostic system based on Kraepelin’s (1899, 1913) inﬂuential textbooks. The APA submitted this system to the American Medical Association for inclusion in its Standard Classiﬁed Nomenclature of Disease; however, a number of weaknesses in the system quickly became apparent (e.g., developed for hospitalized patients, it was less relevant for acute conditions and it did not integrate psychoanalytic theory, which had become popular in the United States at that time). Due to these problems with the Kraepelin-based system, military hospitals and Veterans Administration hospitals each developed its own classiﬁcation system. These systems were often discordant and created communication difﬁculties. In 1951 the United States Public Health Services commissioned representatives from the American Psychiatric Association to standardize the diagnostic systems used in the United States, which resulted in the DSM-I, published in 1953. The ﬁrst edition of DSM was a glossary describing various diagnostic categories based on Adolf Meyer’s developmental psychobiologic views. DSM-I described 108 separate disorders. Many of these disorders were described as reactions to environmental conditions that could result in emotional problems. The second edition of the DSM (1968) was based on a classiﬁcation of mental disease derived from the 8th revision of the International Classiﬁcation of Diseases (ICD-9). DSM-II distinguished between neurotic disorders and psychotic disorders, and speciﬁed 182 different disorders. Except for the description of the neuroses, which were strongly inﬂuenced by psychodynamic thought, DSM-II did not provide a theoretical framework for understanding nonorganic mental disorders. Descriptions of various psychiatric disorders in DSM-II were based on the best clinical judgment of a committee of experts and its consultants (Widiger, Frances, Pincus, Davis, & First, 1991). Narcissism or narcissistic personality disorder was not an ofﬁcial diagnosis in either DSM-I or II.

Narcissistic personality disorder (NPD) was ﬁrst introduced into the ofﬁcial diagnostic system in Diagnostic and Statistical Manual of Mental Disorders-III (DSM-III, 1980) owing to the widespread use of the concept by clinicians, the writings of Kernberg, Kohut, and Millon, and the identiﬁcation of narcissism as a personality factor in a number of psychological studies (Ashby et al., 1979; Block, 1971; Cattell, Horn, Sweney, & Radcliffe,1964; Exner, 1969, 1973; Eysenck, 1975; Frances, 1980; Harder, 1979; Leary, 1957; Murray, 1938; Pepper & Strong, 1958; Raskin & Hall, 1979; Serkownek, 1975). See Chapter 2 (this volume) for a history of the evolution of the narcissistic personality disorder diagnosis from DSM-III to DSM-IV-R. Although many of the changes to NPD criteria from the DSM-III to –III-R and IV, were the result of increased attention to empirical ﬁndings, Cain, Pincus, and Ansell (2008) note that it also resulted in the elimination of many underlying vulnerable themes. Others have stressed this idea, too (Cooper, 2000; Levy, Reynoso, Wasserman, & Clarkin, 2007). Additionally, much of the dynamic aspect of the disorder in terms of shifts and vacillations between mental states or in behavior were also eliminated. Finally, one could argue that some aspects of the change in criteria represented a concern with discriminating NPD from other disorders and reducing comorbidity at the expense of the true phenomenological nature of the disorder.

SUBTYPES

The changes in DSM-III-R and –IV led to a number of critiques that DSM has failed to capture the intended clinical phenomena (Cain et al., 2008; Cooper, 2000; Cooper & Ronningstam, 1992; Gabbard, 1989; Gunderson, Ronningstam, & Smith, 1991; Levy et al., 2007). These authors have noted that changes to the DSM criteria set have increasingly stressed the overt and grandiose aspects of narcissism while at the same time de-emphasizing and eliminating references to the more vulnerable aspects of narcissism. A number of clinical and academic authors, such as A Historical Review of Narcissism and Narcissistic Personality

Cooper (1981), Akhtar and Thomson (1982), Gabbard (1989), and Wink (1991) have suggested that there are two subtypes of NPD: an overt form, also referred to as grandiose, oblivious, willful, exhibitionist, thick-skinned, or phallic; and a covert form, also referred to as vulnerable, hypersensitive, closet, or thin-skinned (Bateman, 1998; Britton, 2000; Gabbard, 1989; Masterson, 1981; Rosenfeld, 1987). The overt type is characterized by grandiosity, attention seeking, entitlement, arrogance, and little observable anxiety. These individuals can be socially charming despite being oblivious of others’ needs, interpersonally exploitative, and envious. In contrast, the covert type is hypersensitive to others’ evaluations, inhibited, manifestly distressed, and outwardly modest. Gabbard (1989) described these individuals as shy and “quietly grandiose,” with an “extreme sensitivity to slight,” which “leads to an assiduous avoidance of the spotlight” (p. 527). Both types are extraordinarily self-absorbed and harbor unrealistically grandiose expectations of themselves. This overt–covert distinction has been empirically supported in at least six studies using factor analyses and correlational methods (Dickinson & Pincus, 2003; Hendin & Cheek, 1997; Hibbard & Bunce, 1995; Rathvon & Holmstrom, 1996; Rose, 2002; Wink, 1992a, 1992b). See Chapter 4 in this volume on the distinction between narcissistic grandiosity and vulnerability.

Rather than distinguishing between overt and covert types as discrete forms of narcissism, Kernberg noted that the overt and covert expressions of narcissism may be different clinical manifestations of the disorder, with some traits being overt and others being covert. Kernberg contended that narcissistic individuals hold contradictory views of the self, which vacillate between the clinical expression of overt and covert symptoms. Thus, the overtly narcissistic individual most frequently presents with grandiosity, exhibitionism, and entitlement. Nevertheless, in the face of failure or loss, these individuals will become depressed, depleted, and feel painfully inferior. The covertly narcissistic individual will often present as shy, timid, and inhibited, but on closer contact, reveal exhibitionistic and grandiose fantasies. In addition to noting phenomenological aspects of narcissism, Kernberg classiﬁed narcissism along a dimension of severity from normal to pathological and distinguished between three levels of pathological narcissism based on the degree of differentiation and integration of representation. These three levels correspond to high-, middle-, and low-functioning groups. At the highest level are those patients whose talents are adequate to achieve the levels of admiration necessary to gratify their grandiose needs. These patients may function successfully for a lifetime, but are susceptible to breakdowns with advancing age as their grandiose desires go unfulﬁlled. At the middle level are patients with NPD proper who present with a grandiose sense of self and little interests in true intimacy. At the lowest level are the continuum of patients who are comorbid with borderline personality, whose sense of self is generally more diffuse and less stable thus more frequently vacillating between pathological grandiosity and suicidality. These individuals’ lives are generally more chaotic. Finally, Kernberg distinguished a type of NPD that he calls malignant narcissism. These patients are characterized by the typical NPD symptoms; however, they also display antisocial behavior, tend toward paranoid features, and take pleasure in their aggression and sadism toward others. Kernberg (1992) posited that these patients are at high risk for suicide, despite the absence of depression. Kernberg suggested that suicidality for these patients represents sadistic control over others, a dismissal of a denigrated world, or a display of mastery over death. Despite the richness of Kernberg’s descriptions, we could ﬁnd no direct research on malignant narcissism. It will be important to differentiate malignant narcissism from NPD proper (as well as from antisocial, paranoid, and borderline personality disorders) and to show that those patients meeting Kernberg’s criteria for malignant narcissism are at risk for the kind of difﬁculties that Kernberg described clinically.

CONTRIBUTIONS FROM SOCIAL-PERSONALITY PSYCHOLOGY

Although assessment and factor analytic research by social and personality psychologists was central for the inclusion of NPD in the DSM-III (Ashby et al., 1979; Block, 1971; Cattell et al., 1964; Frances, 1980; Harder, 1979; Leary, 1957; Murray, 1938; Pepper & Strong, 1958; Raskin & Hall, 10

Narcissism and NPD: Constructs and Models

1979; Serkownek, 1975), it is more recent research from this area that is now inﬂuencing theories regarding narcissism. Some of this work has conﬁrmed past clinical observations and theorizing, such as linking narcissism to shame (Gramzow & Tangney, 1992), perceptions of victimhood (McCullough, Emmons, Kilpatric, & Mooney, 2003), and aggression (Pincus et al., 2009).

Other social-psychological research is challenging long-held assumptions. Although this work needs to be conﬁrmed, a number of researchers have found that the idea that narcissism is a defensive cover for low self-esteem is not supported by the evidence (Baumeister et al., 2000). These ﬁndings combined with ﬁndings that narcissism is associated with higher self-esteem, has led some to contend that narcissism is more of an addiction to high self-esteem than a defense against low self-esteem (Baumeister & Vohs, 2000). Consistent with this conclusion, creative studies using the Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998) suggest that narcissism is correlated with implicit self-esteem (Campbell, Bosson, Goheen, Lakey & Kernis, 2007; Jordan, Spencer, Zanna, Hoshino-Browne, & Correll, 2003; Zeigler-Hill, 2006).

SUMMARY AND CONCLUSION

Although its place in history is secure, with DSM-5 on the horizon the future of narcissism and NPD is uncertain. Current conceptions of DSM-5 do not include NPD among the ﬁve major personality disorder types. However, aspects of NPD are included in the remaining three components of the proposed model (level of personality functioning, general personality dysfunction, and personality traits). Thus, the personality disorder workgroup suggests that narcissistic functioning can be captured through the use of this hybrid model. The workgroup has proposed that the new model allow for a multidimensional assessment of narcissism, which will provide a more nuanced portrait. Of course, the ﬁnal conceptualization of narcissism or NPD in DSM-5 awaits more data from ﬁeld trials and debate within the scientiﬁc community, and regardless of how it is included in DSM-5, research on the concept will continue. One thing is for certain: despite its rich history, contributions for understanding clinical phenomena, and broad inﬂuence for conceptualizing trends in society, narcissism has only relatively recently begun to receive its due attention. The inclusion of NPD in the DSM-III led to an upsurge of research, but data suggest that this interest has leveled off (Konrath, 2008). Despite this ﬁnding, research ﬁndings from clinical psychology and psychiatry as well as social-personality psychology suggest that more intensive focus on narcissism is needed.

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