case study of narcissistic personality disorder

The Narcissistic Patient - A Case Study

What are the traits of a narcissist? Read therapy session notes from man diagnosed with Narcissistic Personality Disorder (NPD).

• Watch the video on Notes of a First Therapist Session  

Notes of first therapy session with Sam V., male, 43, diagnosed with Narcissistic Personality Disorder (NPD)

Sam presents with anhedonia (failure to enjoy or find pleasure in anything) and dysphoria bordering on depression. He complains of inability to tolerate people's stupidity and selfishness in a variety of settings. He admits that as a result of his "intellectual superiority" he is not well placed to interact with others or even to understand them and what they are going through. He is a recluse and fears that he is being mocked and ridiculed behind his back as a misfit and a freak. Throughout the first session, he frequently compares himself to a machine, a computer, or a member of an alien and advanced race, and talks about himself in the third person singular.

Life, bemoans Sam, has dealt him a bad hand. He is consistently and repeatedly victimized by his clients, for instance. They take credit for his ideas and leverage them to promote themselves, but then fail to re-hire him as a consultant. He seems to attract hostility and animosity incommensurate with his good and generous deeds. He even describes being stalked by two or three vicious women whom he had spurned, he claims, not without pride in his own implied irresistibility. Yes, he is abrasive and contemptuous of others at times but only in the interests of "tough love." He is never obnoxious or gratuitously offensive.

Sam is convinced that people envy him and are "out to get him" (persecutory delusions). He feels that his work (he is also a writer) is not appreciated because of its elitist nature (high-brow vocabulary and such). He refuses to "dumb down". Instead, he is on a mission to educate his readers and clients and "bring them up to his level." When he describes his day, it becomes clear that he is desultory, indolent, and lacks self-discipline and regular working habits. He is fiercely independent (to the point of being counter-dependent - click on this link: The Inverted Narcissist ) and highly values his self-imputed "brutal honesty" and "original, non-herd, outside the box" thinking.

He is married but sexually inactive. Sex bores him and he regards it as a "low-level" activity practiced by "empty-headed" folk. He has better uses for his limited time. He is aware of his own mortality and conscious of his intellectual legacy. Hence his sense of entitlement. He never goes through established channels. Instead, he uses his connections to secure anything from medical care to car repair. He expects to be treated by the best but is reluctant to buy their services, holding himself to be their equal in his own field of activity. He gives little or no thought to the needs, wishes, fears, hopes, priorities, and choices of his nearest and dearest. He is startled and hurt when they become assertive and exercise their personal autonomy (for instance, by setting boundaries).

Sam is disarmingly self-aware and readily lists his weaknesses and faults - but only in order to preempt real scrutiny or to fish for compliments. He constantly brags about his achievements but feels deprived ("I deserve more, much more than that"). When any of his assertions or assumptions is challenged he condescendingly tries to prove his case. If he fails to convert his interlocutor, he sulks and even rages. He tends to idealize everyone or devalue them: people are either clever and good or stupid and malicious. But, everyone is a potential foe.

Sam is very hypervigilant and anxious. He expects the worst and feels vindicated and superior when he is punished ("martyred and victimized"). Sam rarely assumes total responsibility for his actions or accepts their consequences. He has an external locus of control and his defenses are alloplastic. In other words: he blames the world for his failures, defeats, and "bad luck". This "cosmic conspiracy" against him is why his grandiose projects keep flopping and why he is so frustrated.

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

next: The Sadistic Patient ~ back t o: Case Studies: Table of Contents

APA Reference Vaknin, S. (2009, October 2). The Narcissistic Patient - A Case Study, HealthyPlace. Retrieved on 2024, April 19 from https://www.healthyplace.com/personality-disorders/malignant-self-love/narcissistic-patient-a-case-study

Medically reviewed by Harry Croft, MD

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Module 12: Personality Disorders

Narcissistic personality disorder, learning objectives.

• Describe the characteristics and diagnosis of narcissistic personality disorder

Now we will review  another Cluster B personality disorder: n arcissistic personality disorder.

Narcissistic personality disorder (NPD) is characterized by the personality traits of persistent grandiosity, an excessive need for admiration, and a personal disdain and lack of empathy for other people. As such, an individual with narcissistic personality disorder (NPD) usually displays arrogance and a distorted sense of personal superiority and seeks to establish abusive power and control over others. Self-confidence (a strong sense of self) is a personality trait different from the traits of narcissistic personality disorder; thus, people with narcissistic personality disorder (NPD) typically value themselves over others, to the extent of openly disregarding the wishes and feelings of anyone else, and expect to be treated as superior, regardless of their actual status or achievements. Socially, the person with NPD usually exhibits a fragile ego (self-concept), intolerance of criticism, and a tendency to belittle other people in order to validate their own superiority.

The DSM-5 indicates that a person with NPD possesses at least five of the following nine criteria, typically without possessing the commensurate personal qualities or accomplishments for which they demands respect and status:

Figure 1.  Individuals with NPD typically value themselves over anyone else.

• is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
• believes that they are special and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
• requires excessive admiration.
• has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with their expectations).
• is interpersonally exploitative (i.e., takes advantage of others to achieve their own ends).
• lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
• is often envious of others or believes that others are envious of them.
• shows arrogant, haughty behaviors or attitudes.

NPD  is a personality disorder characterized by a long-term pattern of exaggerated feelings of self-importance, an excessive craving for admiration, and struggles with empathy. People with NPD often spend much time daydreaming about achieving power and success, or on their appearance. People with the diagnosis in recent years have spoken out about its stigma in media, and possible links to abusive situations and childhood trauma. Such narcissistic behavior typically begins by early adulthood and occurs across a broad range of situations.

Epidemiology

The lifetime rates of narcissistic personality disorder are estimated at 1% in the general population; and between two to 16% in the clinical population.

Narcissistic personality disorder usually develops either in adolescence or in early adulthood,  and it is common for children and adolescents to display personality traits that resemble NPD, but such occurrences are usually transient, and register below the clinical criteria for a formal diagnosis of NPD.  True symptoms of NPD are pervasive, apparent in varied social situations, and rigidly consistent over time. Severe symptoms of NPD can significantly impair the person’s mental capabilities to develop meaningful human relationships, such as friendship, kinship, and marriage. The DSM-5 indicates that, in order to qualify as symptomatic of NPD, the person’s manifested personality traits must substantially differ from the cultural norms of society.

The causes of narcissistic personality disorder are unknown, but theorized to be linked to certain types of traumas.  A combination of genetic, environmental, and social factors are involved in narcissistic personality disorder. 

Narcissistic personality disorder usually develops either in adolescence or in early adulthood, and it is common for children and adolescents to display personality traits that resemble NPD, but such occurrences are usually transient and register below the clinical criteria for a formal diagnosis of NPD. True symptoms of NPD are pervasive, apparent in varied social situations, and are rigidly consistent over time. Severe symptoms of NPD can significantly impair the person’s mental capabilities to develop meaningful human relationships, such as friendship, kinship, and marriage. Generally, the symptoms of NPD also impair the person’s psychological abilities to function socially, either at work, or at school, or within important societal settings. The DSM-5 indicates that, in order to qualify as symptomatic of NPD, the person’s manifested personality traits must substantially differ from the cultural norms of society.

Figure 2.  NPD can give individuals inflated perceptions about themselves.

Narcissistic personality disorder is rarely the primary reason for which people seek mental health treatment. Therapy is difficult because people with narcissistic personality disorder usually do not consider their own issues as symptoms, despite mental distress. When people with NPD enter treatment, they usually are prompted by difficulties in their lives, or are seeking relief from some other disorder of their mental health, such as a major depressive disorder, drug addiction, or manic depression.

The reason for such an indirect path to psychotherapy is partly because an individually with NPD generally possess poor insight, and are unaware that their actions produced their mentally unhealthy circumstance, and so fail to recognize that their perceptions and behaviors are socially inappropriate and problematic, because of their very positive self-image (inflated self-concept).

Comorbidity

The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders. People with NPD are prone to bouts of psychological depression, often to the degree that meets the clinical criteria for a co-occurring depressive disorder. Moreover, the occurrence of NPD is further associated with the occurrence of bipolar disorder and substance use disorders, especially cocaine use disorder.

This video further explains and gives examples of narcissism.

You can view the transcript for “The psychology of narcissism – W. Keith Campbell” here (opens in new window) .

Key Takeaways: Narcissistic Personality Disorder

Case study: narcissistic personality disorder.

A 42-year-old male professional in public office, Edgar, was forced to resign after being arrested when visiting a brothel. In the aftermath, he suffered from depression, considerable alcohol consumption, and was admitted for a three-month treatment. He stopped drinking, but his depression remained unresponsive to anti-depressant medication. Still, without meaningful activities, he felt empty, restless, and was eventually referred to psychotherapy.

Developmental history indicates that at age five, Edgar’s father left the family and they did not meet again until he was in law school. He was always ahead of his age and went through school without difficulty. In law school, he got high marks without hard work. He had many acquaintances, but no close friendships, and always felt like an outsider. He got married and had two children. Reaching his mid-thirties, Edgar felt bored. He had everything: house, career, and family. He was respected and accomplished but felt he didn’t belong. He started drinking heavily and visiting brothels.

The psychotherapist found him self-assured, easily irritated, and quick to make devaluing remarks. Interactions during weekly appointments were extremely difficult. Unwilling to explore his situation or his feelings, he blamed the therapist for the impasse and told the therapist that he would not change and that the therapist could not help. The therapist dreaded the appointments, while the patient, despite finding the sessions unhelpful, always showed up. When the therapist announced a three-week break, Edgar suggested the treatment end and did not return. Nine months later, Edgar informed the therapist that he moved to another city, had a leading position working with international trade, and was greeted as a king. He said nothing about his wife and children. Nor did he indicate how he felt about the treatment.

narcissistic personality disorder:  a Cluster B personality disorder characterized by a pattern of grandiosity, a need for admiration, and a lack of empathy.

• Textbook of Psychiatry. Authored by : Wikibooks. Located at : https://en.wikibooks.org/wiki/Textbook_of_Psychiatry/Print_version#Cluster_B . License : CC BY-SA: Attribution-ShareAlike
• Narcissistic Personality Disorder. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Narcissistic_personality_disorder . License : CC BY-SA: Attribution-ShareAlike
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A Cognitive-Behavioral Formulation of Narcissistic Self-Esteem Dysregulation

• Erik C. Nook , Ph.D. ,
• Adam C. Jaroszewski , Ph.D. ,
• Ellen F. Finch , M.A. ,
• Lois W. Choi-Kain , M.Ed., M.D.

Search for more papers by this author

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

It makes sense to want to feel good about oneself. Decades of research suggest that high self-esteem—one’s evaluation of how good, competent, attractive, influential, and socially regarded one is ( 1 – 4 )—portends positive mental health outcomes ( 5 – 7 ). However, it is possible to have too much of a good thing. A grandiose sense of self-importance, entitlement, and need for admiration can produce considerable intrapersonal and interpersonal difficulties, culminating into a diagnosis of narcissistic personality disorder (NPD) ( 8 , 9 ), an impairing condition that affects 1%–6% of the U.S. population ( 10 , 11 ). What distinguishes healthy self-esteem from narcissistic grandiosity? We begin by summarizing research on this question, arriving at the notion that self-esteem regulation is a transdiagnostic psychological process that becomes dysregulated in NPD. We then articulate a cognitive-behavioral formulation of narcissistic self-esteem dysregulation, showing how this dysregulation can be seen as interactions between beliefs, thoughts, feelings, and behaviors. This broadly applicable perspective offers hope for NPD treatment, as it renders self-esteem dysregulation amenable to intervention through cognitive-behavioral therapy (CBT), which has been found effective for several other psychiatric disorders. We then illustrate how key CBT techniques could be applied before concluding with a discussion of the implications of the model and future directions of research.

Narcissism and Its Treatment

Over decades of scholarship spanning psychoanalytic traditions, personality psychology, and clinical science, researchers have sought to characterize the psychological processes that drive pathological narcissism. Although numerous theoretical frameworks have been developed and continue to evolve, they share an understanding that maladaptive patterns of self-esteem regulation are central to pathological narcissism ( 12 ). Data show that, unlike normative, healthy self-esteem, which is associated with positive outcomes ( 5 – 7 ), narcissistic self-esteem is fragile, because it is highly contingent on achievement-related successes and feedback from the social environment ( 13 – 15 ).

Narcissistic self-esteem is thus conceptualized as precariously elevated. When an individual with NPD is faced with an ego threat (e.g., real or imagined criticism, failure, or reduced social regard), unrealistically high self-expectations crumple into perceived inferiority ( 16 , 17 ). Individuals with NPD are, therefore, hypersensitive to ego threats, and when threatened, they respond with efforts to reduce concomitant distress and upregulate self-esteem ( 17 – 19 ). These regulation strategies include some of NPD’s most recognizable and maladaptive behaviors. Classic “grandiose” responses include being aggressive or devaluing toward others ( 20 , 21 ), fixating on grandiose fantasies ( 22 ), or engaging in self-serving bias ( 23 ). Classic “vulnerable” responses include alienating and isolating themselves ( 24 ) by avoiding situations that may threaten self-esteem ( 25 ), relentlessly criticizing themselves ( 26 – 28 ), or engaging in suicidal behaviors and fantasies ( 29 , 30 ). This vacillation between overly inflated and deflated self-appraisals, alongside efforts to regulate this unstable sense of self through grandiosity, flawlessness, and/or avoidance, are described in both early psychoanalytic theories of narcissism ( 31 ), the contemporary Alternative DSM-5 Model for Personality Disorders ( 8 ), and the personality disorder section of the ICD-11 ( 32 – 34 ).

It is important to note that research is continually adding nuance to scientific perspectives on self-esteem in NPD ( 35 ). Various frameworks differently emphasize shifts between distinct states of grandiosity (i.e., elevated self-esteem, arrogance, and entitlement) and vulnerability (i.e., shame, insecurity, and neuroticism). Scholars are working to clarify whether and how grandiosity may function to conceal ever-present vulnerability and whether fragile self-esteem is a driving force or an outcome of this process ( 17 , 18 , 26 , 36 ). Recent proposals also offer a more complex and dynamic view beyond shifting grandiosity and vulnerability ( 35 ). In the midst of the field coming to a consensus regarding how to best conceptualize “narcissism,” we offer a cognitive-behavioral model proposing that symptoms of NPD are driven by narcissistic self-esteem dysregulation, which is characterized by fragile self-esteem (maintained by unrealistic beliefs about one’s importance, abilities, influence, or social regard) and habitual maladaptive behavioral strategies that prop up elevated self-esteem.

Despite the high prevalence of harmful outcomes of NPD, few psychotherapeutic treatments for NPD exist, and none have been empirically tested ( 12 , 37 ). Existing treatments for narcissistic processes are largely psychoanalytic ( 38 , 39 ). More recently, evidence-based psychotherapies for borderline personality disorder, a related but distinct diagnosis from NPD, have steadily been adapted for NPD. Transference-focused psychotherapy ( 40 ), mentalization-based treatment ( 41 ), good psychiatric management ( 42 ), and dialectical behavior therapy ( 43 ) have all adjusted protocols originally for borderline personality disorder to more directly address the unique aspects of NPD. However, none of these adapted therapies have been systematically tested, and developing accessible and pragmatic NPD treatments is critical ( 44 , 45 ). Given its effective application to a wide range of disorders, CBT stands as a clear choice for guiding the development of novel NPD interventions.

The CBT Model

CBT is a family of short-term, structured, and problem-focused psychotherapeutic treatments that primarily utilize cognitive (thought- and meaning-related) and behavioral (response- and action-related) interventions aimed at improving psychological functioning ( 46 , 47 ). The central theoretical model underlying CBT posits that thoughts, behaviors, and emotions dynamically influence and maintain one another. These processes ideally serve adaptive functions, such as helping individuals accomplish their goals, navigate their environment, and ultimately survive ( 48 ). However, sometimes these cognitive-behavioral systems become dysregulated and produce symptoms of psychopathology. As we illustrate later, this is particularly the case when individuals believe that they cannot cope with situations that are actually tolerable and when they maintain these beliefs by habitually avoiding or escaping unwanted emotions aroused by situations that trigger these emotions ( 49 ). CBT models have been tailored to treat specific disorders, such as major depressive disorder ( 50 , 51 ), posttraumatic stress disorder (PTSD) ( 52 , 53 ), and borderline personality disorder ( 54 ). Transdiagnostic approaches such as the Unified Protocol ( 49 ) and the Modular Approach to Treating Children (or MATCH) ( 55 ), have also been developed to treat multiple disorders simultaneously or serially.

A transdiagnostic CBT model is presented in Figure 1 , which we illustrate using an example patient with social anxiety disorder. The patient’s highly distressing fears that they will embarrass themselves lead to chronic avoidance of social situations. CBT typically begins with psychoeducation, in which patients learn how emotions have adaptive functions (e.g., anxiety helps prepare for and avoid possible danger) and how they are are beneficial when calibrated to reality (i.e., aligned and proportionate to the facts of a given situation) ( 56 ). Through both didactic discussion and self-monitoring homework exercises, patients learn about the CBT model of psychopathology. They learn to see their symptoms as recurring cycles of thoughts, feelings, and behaviors; how these cycles emerge in response to situations because of underlying belief systems; and how habitual cognitive and behavioral reactions to these situations only serve to reinforce these beliefs, thereby maintaining their problem.

FIGURE 1. General cognitive-behavioral therapy (CBT) model, illustrated using an example patient with social anxiety disorder indicated in gray text a

a In CBT, patients learn to see their psychological experiences as composed of three components visualized by the circles in the center of the model: thoughts (i.e., their automatic interpretations and narratives about the world), feelings (i.e., their physiological and emotional reactions), and behaviors (i.e., the ways they choose to respond to situations). These three components continuously influence each other and comprise the patient’s symptoms. These reactions emerge because of how beliefs (i.e., one’s inner network of commitments, assumptions, expectations, and predictions about the world, symbolized by the rightward-pointing arrow) interact with specific situations. For example, when this patient is invited to a party, their belief that embarrassment is unbearable leads them to think about what a fool they will be, generating substantial anxiety and a desire to avoid the party. Patients also learn how behaviors in the avoidant path (lower line ending in an arrow symbol) move them away from the situations and emotions that bring them distress. Although this often immediately reduces their distress, it only reinforces their underlying beliefs (e.g., avoiding parties keeps one “safe” from embarrassment). Because this reinforces the underlying belief, they re-experience the same reactions to similar situations in the future. Patients thus are encouraged to choose the approach pathway (upper line ending in a horizontal bar, which represents “blocking” the belief). These behaviors bring them close to their feared situations, which temporarily increases distress but helps them learn new things about the world and erode their underlying beliefs. For example, attending the party gives the patient an opportunity to learn that they can tolerate (or even enjoy) social situations. Transforming the patient’s beliefs (e.g., to “I can handle embarrassment” or “socializing can be fun, even if I might mess up”) allows them to engage with social situations with reduced distress and avoidance.

For example, when a patient is invited to a party, the belief that “embarrassment is unbearable” becomes activated, leading to a negative automatic thought (e.g., “I’ll probably make a fool of myself”) and concomitant feelings (e.g., anxiety, elevated heart rate, or tension or tightness in the pit of their stomach). Although habitual strategies for regulating these feelings (e.g., avoiding the party) may immediately reduce distress, they only reinforce the maladaptive belief that embarrassment is unbearable by generating additional evidence that one must avoid social gatherings to be “safe” from embarrassment. Reinforcing this belief means that the same cycle of symptoms will arise in future social situations. During treatment, these behaviors will consequently be labeled as part of an “avoidant” pathway that is ultimately unhelpful to long-term well-being. The patient will be encouraged to replace these avoidant responses with skills that move them down an “approach” pathway. Although approaching social situations and embarrassment (e.g., attending parties or speaking in social settings) can generate distress, doing so gives patients evidence that can erode underlying maladaptive beliefs. For example, signing up for improvisation classes and learning that they can survive an hour in the spotlight can help patients form new beliefs that embarrassment is tolerable, thus freeing them from social anxiety. Note that although this example focuses on social anxiety disorder, these dynamics are also highly relevant to narcissistic dysregulation (discussed later).

There are many CBT techniques for shifting patients from avoidance to approach pathways and transforming their underlying beliefs. Two major classes of interventions include cognitive and behavioral skills. Cognitive interventions ultimately aim to increase the flexibility with which patients think about themselves, others, and the world ( 57 ). Patients first learn about different layers of cognition, including their “automatic thoughts” (i.e., immediate, situation-specific interpretations that come to a person’s mind throughout the day), “intermediate beliefs” (i.e., general attitudes and assumptions that give rise to automatic thoughts such as, “If I don’t wash my hands, then I’ll get sick”), and “core beliefs” (i.e., the deep, long-standing, and rigid beliefs about oneself and the world that can be expressed in simple declarations like, “I’m unlovable”) ( 58 ). Patients then learn cognitive techniques that they can use to challenge and change these layers of cognition. Using cognitive restructuring to summon evidence against one’s automatic thoughts and generate alternative interpretations can help improve mood and reduce symptoms ( 59 – 62 ). Cognitive interventions provide patients with the skills to change their thoughts and beliefs (indicated by a circle and an arrow, respectively, in Figure 1 ).

Behavioral interventions challenge patients to directly change their behavior (indicated by a circle in Figure 1 ), giving them evidence that interrupts their beliefs (indicated by an arrow in Figure 1 ) and helps free them from the cycle of their symptoms. After patients develop an awareness of the behaviors they habitually use to avoid uncomfortable emotions, they then engage in “behavioral experiments,” “exposure exercises,” or “behavioral activation plans” in which they purposefully confront situations that they fear and avoid. These can be a wide variety of activities, including giving a speech in front of strangers, sending e-mails with typos in them, holding doorknobs that might have germs on them, planning positive events, or any other exercises that help them approach situations or sensations that they fear or avoid. A substantial body of research shows that behavioral exposures can drastically reduce a patient’s fear and avoidance of these situations, thereby improving their functioning ( 63 – 70 ). Theoretically, the patient begins to build new associations with these situations that foster the belief that they can cope ( 71 ). Of key importance is that patients learn to resist avoidant (or “safety”) behaviors during exposures (e.g., taking lorazepam before every exposure or washing their hands immediately after the exposure), as this inhibits the patient’s learning that they can cope with feared situations or emotions without avoidance ( 72 ). Some exposure exercises can be extremely distressing, meaning that providing a clear rationale for this approach and collaboratively working up to more difficult exposures are essential for the sustainability of this powerful and empirically proven intervention.

Meta-analyses show that treatments under the CBT umbrella improve symptoms and are often considered the gold-standard treatment for a wide range of psychiatric presentations ( 73 , 74 ). This list includes internalizing disorders, such as major depressive disorder ( 66 , 75 ), social anxiety disorder ( 76 ), panic disorder ( 67 , 77 ), and PTSD ( 78 , 79 ); externalizing disorders, such as drug and alcohol use ( 80 ), attention-deficit hyperactivity disorder ( 81 ), and oppositional defiant disorder ( 82 ); personality disorders, including borderline personality disorder ( 83 , 84 ) and personality disorders comorbid with other disorders such as PTSD ( 85 ) or major depressive disorder ( 86 ); suicidal thoughts and behaviors ( 87 ); bipolar disorder ( 88 ); and psychosis ( 89 , 90 ). The time has come to consider how CBT could be adapted for NPD and self-esteem dysregulation more broadly.

A CBT Formulation of Narcissistic Self-Esteem Dysregulation

Generating a CBT approach to NPD requires identifying the key beliefs that generate dysregulation, the habitual avoidant behaviors that reinforce those beliefs, and a potential set of cognitive and behavioral interventions that could interrupt these habits and transform maladaptive beliefs to healthier versions. We outline these three steps in the present section, drawing on the principles and literature outlined in the previous sections. A conceptual model of healthy and unhealthy self-esteem dysregulation is illustrated in Figure 2 . Healthy individuals, overall, have relatively positive and stable self-esteem, which is consistently connected to reality ( Figure 2A ). This means that one holds reasonable expectations of oneself and how one should be treated. Healthy self-esteem is still sensitive to environmental feedback, falling when there are threats to one’s self-esteem and rising when one’s abilities and standing are affirmed. Self-esteem threats involve challenges to one’s competence, influence, attractiveness, social regard, or overall “goodness” (e.g., when rejected, when receiving negative feedback, or when performing worse than others). Scholars agree that experiences in which one suffers decreased self-esteem generate negative emotions including shame, embarrassment, envy, anxiety, and anger ( 13 , 20 , 91 ). These threats and concomitant emotions then activate efforts to “restore” self-esteem that both alleviate negative emotions aroused by the self-esteem threat and (when operating optimally) help the person grow their skills, social regard, and potential to contribute to society. In other words, self-esteem regulation is “the spice of life,” as it is a healthy and powerful promoter of both intrapersonal and interpersonal functioning ( 12 ). Being able to maintain this healthy self-esteem regulation circuit requires maintaining reasonable expectations for oneself and choosing constructive means for restoring self-esteem. This healthy regulation thus flows from a set of core beliefs such as “like others, I have natural strengths and weaknesses,” “I can get better at things through hard work,” and “I have inherent value.”

FIGURE 2. Cognitive-behavioral (CBT) model of healthy and unhealthy narcissistic self-esteem, with examples indicated in gray text a

a Both (A) and (B) show self-esteem levels fluctuating across time, with higher points on the Y axis reflecting more positive self-regard. The dark horizontal line in each panel represents feeling “neutral” about oneself, and values below this line represent feeling negatively about oneself. The gray shaded region represents self-esteem that is connected to reality (i.e., reasonable expectations of one’s own competence, influence, and social regard). (A) Healthy self-esteem and its regulation. Healthy self-esteem is typically stable and positive. However, even healthy self-esteem is responsive to negative feedback, depicted by the downward-pointing arrow (e.g., failing an examination). These “self-esteem threats” naturally trigger decreases in self-esteem and negative affect. In healthy individuals, one’s self-esteem system then launches responses that work to restore self-esteem (e.g., studying hard and passing the next examination). Underlying this person’s self-esteem is a core belief such as “I have natural strengths and weaknesses.” (B) Unhealthy self-esteem and its regulation. Here, self-esteem is frequently oscillating from unrealistically high to unrealistically low levels (e.g., “No one is as good as me” to “I’m worthless”). This unrealistically high evaluation of oneself renders self-esteem highly fragile, and daily interactions with reality threaten self-esteem (e.g., not being sufficiently praised for one’s work). This triggers a flip in self-esteem to unrealistically low levels that require excessively strong reactions to “restore” (e.g., insulting someone else’s intelligence to regain a sense of superiority). This fluctuation reflects the operation of a core belief such as, “If I’m not the best, I’m worthless.” These systems of self-esteem (dys)regulation can be understood within the CBT model depicted in Figure 1 .

However, this system can easily become dysregulated, leading to narcissistic symptoms (and, in extremes, NPD). This dysregulation can take many forms, but the key point of fragility lies at the interface of unrealistic expectations of oneself and destructive means for restoring self-esteem (for examples, see Figure 2B and Table 1 ). If a person believes that they are not valuable unless they attain extraordinarily high standards (e.g., “if I’m not the best, I’m worthless” or “I deserve praise for all that I do”), then even quotidian experiences will threaten one’s self-esteem. Insufficient acknowledgment, minor mishaps, or exposure to more accomplished others will all trigger cognitions and emotions reflecting an extreme dip in self-esteem in which one feels incompetent and valueless. Indeed, narcissism is associated with elevated negative affect in response to others’ dominance ( 92 ). This distress can then trigger excessive behavioral reactions aimed at downregulating emotions, restoring self-esteem to unrealistically high standards ( 19 ), for example, by bringing others “down a peg,” behaving pompously, or giving up. In our model, these behavioral reactions can vary across individuals, but all aim to restore self-esteem (see Table 1 for examples). In fact, it is possible that the documented differences in “vulnerable” and “grandiose” subtypes of NPD ( 93 , 94 ) could be explained by different behavioral strategies that patients use to restore their self-esteem. For instance, a “vulnerable” narcissistic profile would emerge from responses that restore esteem by removing oneself from potential sources of ego threat (e.g., not engaging during class, not responding to friends, or seeking suicide). A “grandiose” presentation would emerge from behaviors that instead elevate one’s comparative standing over others (e.g., flaunting one’s successes, putting others down, or defying rules).

TABLE 1. Understanding psychological disorders through cognitive-behavioral therapy components

Special consideration should be given to the function of suicidal thoughts and behaviors (STB) in narcissistic dysregulation, particularly fantasizing about suicide or acting on suicidal urges ( 30 ). As we have noted, narcissistic dysregulation can produce immense and frequent distress, which can generate a desire to downregulate and escape these painful feelings through death. Although such a desire to escape distress can motivate STB transdiagnostically ( 95 , 96 ), suicidal ideation and urges can serve additional functions in NPD, as suicide can seem like a pathway to quit a life in which one’s self-concept is irrevocably tarnished with no way to meet one’s idealized expectations ( 97 ); gain ultimate control over one’s life by permanently ending it; restoring one’s standing relative to others by vengefully showing others that they were insufficient to help; or achieving a glorified version of one’s death ( 30 ). Although these perceived benefits of dying by suicide might temporarily restore one’s sense of agency or relative standing to others, they also obviously bring immense pain to oneself and one’s community. As such, STB should be targeted early in treatment and understood within the aforementioned functional model.

To summarize this model, we propose that self-esteem regulation is a natural psychological process in human beings. People experience threats to their self-esteem, which generates aversive emotions that are regulated through learned behaviors that seek to restore self-esteem. This regulatory cycle is governed by (and, in turn, reinforces) underlying core beliefs about oneself and the world. Healthy self-esteem emerges when people have reasonable beliefs about oneself and use constructive responses to restore self-esteem. Unhealthy self-esteem emerges when people have unrealistic beliefs about themselves and others, leading to frequent self-esteem threats and immense, destructive attempts to restore self-esteem.

Furthermore, this dysregulated cycle can be understood through the lens of the CBT model described in Figure 1 . When someone with NPD is exposed to a situation that threatens their self-esteem, underlying beliefs become activated that produce distorted cognitions and intense emotions. Habitual behavioral responses can momentarily reduce negative emotions and restore self-esteem, but they only reinforce the maladaptive belief, recapitulating the cycle each time the individual’s self-esteem is threatened. Specific examples of this cycle are articulated in Table 1 . Behaviors indicative of classic narcissistic traits (e.g., need for admiration, fantasies of infinite success, suicidality, haughtiness, grandiose self-importance, and envy) can be understood through CBT components. Because of unrealistic underlying beliefs, any situations that threaten one’s sense of value, competence, power, and control germinate automatic thoughts organized around restoring a perceived sense of superiority. These thoughts provoke strong emotions, motivating internal and external behavioral reactions (e.g., escaping, lying, or aggressing) that may, indeed, restore a perceived sense of safety, perfection, or superiority but at the cost of healthy interpersonal functioning. Furthermore, these reactions only reinforce the underlying belief that perceived superiority is worth attaining at all costs. Although we chart only a few examples of narcissistic thought-feeling-behavior cycles, we use them to illustrate what we believe is a general process underlying dysregulated self-esteem.

The key benefit of analyzing narcissistic self-esteem dysregulation through this lens is that it opens this psychological process to modification through CBT techniques. Many relevant therapeutic skills fall under the umbrella of CBT, but we outline key potential approaches in the following text and in Table 2 . CBT typically begins with psychoeducation on the CBT model and how it connects to a patient’s current symptoms. As such, we argue that patients with NPD should be informed of the diagnosis and fully brought into the conversation regarding their clinical conceptualization ( 42 ). After reviewing the models illustrated in Figures 1 and 2 , therapists can assign patients to use self-monitoring exercises to gain a greater awareness of what behaviors they might use to “restore” their self-esteem, which could be maladaptive in nature. Therapists and patients can then explore and identify the deeper assumptions and beliefs that underlie these ego sensitivities. The goal of this information-gathering stage is to build a working knowledge of how patients’ habitual cognitions and avoidant behaviors emerge from and reinforce their underlying beliefs. This serves as a foundation for learning cognitive and behavioral skills that can change these habitual responses and the beliefs that produce them.

TABLE 2. Example applications of cognitive-behavioral therapy (CBT) techniques to narcissistic dysregulation

Cognitive skills for narcissistic dysregulation would help patients habitually challenge automatic thoughts that generate distress and only reinforce underlying maladaptive beliefs. Automatic cognitions are likely to suffer from classic “cognitive distortions” through which thoughts and interpretations neglect parts of reality ( 58 ). For example, cognitions might habitually deny the positive aspects of situations (e.g., thinking “I’m a failure” when patients receive both praise and critical feedback) or taking responsibility for an outcome even when all things are multiply determined (e.g., thinking “no one else is doing anything to make this project succeed” when collaborating on a project). Patients can then learn strategies for being more skeptical about these automatic thoughts and perhaps restructure them. For example, patients can learn to attend to the evidence that they still have value even when they are imperfect or that group projects benefit from shared effort and control. In these ways, habitual restructuring can help soothe negative affect in the face of self-esteem threats and regulate the patient’s behavioral attempts to restore self-esteem.

There are also several behavioral skills that could help stabilize narcissistic dysregulation. These interventions would focus on helping patients approach distressing situations, cognitions, and emotions that they typically avoid in order to learn that they can tolerate these experiences without the need for their habitual destructive reactions. This facilitates a corrective experience in which patients learn new beliefs that the situations that they typically avoid are actually tolerable. When treating narcissistic dysregulation, the goal of behavioral exposures would be to help patients approach situations that threaten self-esteem (which they typically avoid) and choose healthier behaviors to restore self-esteem rather than their typical strategies. Gaining mastery through more effective coping generates more durable self-esteem. For instance, someone with the belief that they must always be seen as the most intelligent person could practice allowing their coworker to take the lead on a project and resist urges to correct them or withdraw from the project. As is well known in exposure-based interventions, this practice can increase distress and requires clear rationale setting and collaboration to help the patient approach and learn from these exposures. One strategy would be to first identify and remove habitual avoidant behaviors in patients’ daily lives (even if they are not related to self-esteem), providing the patient with practice in habituating to strong emotions and engendering confidence in behavioral skills. The ultimate goal is for patients to develop increased willingness to approach situations they typically avoid and healthier skills for managing the emotions that are generated by them, thereby changing their underlying belief network and alleviating their overall symptoms ( 98 ).

We outline a CBT approach to narcissistic self-esteem dysregulation that most mental health professionals can easily adapt into their practice. Narcissistic traits can be understood as a set of habitual thoughts, feelings, and behaviors that emerge because of maladaptive beliefs about oneself that essentially set unrealistic expectations for oneself and how one should be treated. When unmet, such expectations lead to rapid and extreme oscillations in self-esteem that generate strong negative emotions and require excessive and destructive reactions to restore self-esteem. However, this cycle can be regulated through cognitive and behavioral interventions that help patients modify their automatic thoughts and approach feared situations and emotions. These exercises can bring beliefs into a healthy connection with reality, relieving patients of their symptoms.

Although several treatments have been developed to aid people affected by narcissistic dysregulation ( 37 – 43 ), cognitive-behavioral perspectives are scarce (although not nonexistent) ( 99 ). We believe that the current formulation provides several advances beyond prior work. In particular, our model unites the perspective that self-esteem dysregulation is at the heart of NPD ( 12 – 15 ) with classic components of CBT theory ( 58 ). In particular, we articulate how rapid self-esteem oscillations typical of narcissistic fragility can be understood through self-perpetuating cycles of cognitive-affective-behavioral dysregulation that emerge from and reinforce maladaptive belief systems . This formulation opens the psychological processes that underlie NPD to modification through classic CBT techniques and to scientific study. Both of these advances are key for the study and treatment of NPD. Further refining a CBT formulation of NPD will allow both scientific and clinical efforts to make greater headway in understanding and treating NPD. This is especially promising, given the power that CBT has in effectively treating many other forms of psychopathology ( 73 , 74 ).

Another key strength of the current model is its potential for understanding “narcissism” as a dimensional (rather than categorical) and transdiagnostic phenomenon. Scholars have questioned categorical taxonomies of psychopathology and instead advocated for identifying the dimensions that might vary continuously in a population and be shared across several disorders ( 32 – 34 , 100 , 101 ). Our model is consistent with this approach, as self-esteem (dys)regulation is a phenomenon that can vary continuously across people and emerge in several forms of psychopathology beyond NPD. In our model, everyone experiences self-esteem threats and has ways to restore self-esteem, and this system merely becomes dysregulated in NPD. We encourage additional attention to the processes that dysregulate the self-esteem system, as we believe this can help clarify what leads to NPD. We also encourage exploration of self-esteem and its dysregulation in other clinical disorders (e.g., borderline personality disorder, depression, perfectionism, obsessive-compulsive disorder, and social anxiety disorder).

It is crucial to keep in mind several limitations of our model as it stands. First and foremost, it remains largely theoretical (emerging from a synthesis of prior research and clinical observation) and, as such, has little direct empirical validation. Research is needed to establish key assumptions of the model (e.g., Do people with NPD endorse maladaptive beliefs concerning self-esteem? Do symptoms of NPD function to regulate distress and restore self-esteem?) and to test the potential use of CBT interventions to treat NPD. A second major limitation is that core beliefs are well known to be highly resistant to modification ( 102 ). This means that the CBT formulation articulated here might require incorporating additional tools and techniques, such as those of schema therapy, which has been shown to be effective in the treatment of personality disorders ( 103 ). This might be especially important in the treatment of NPD, as people who are highly ashamed of feeling inferior or incompetent are likely to use destructive reactions to restore self-esteem in the context of treatment ( 19 , 99 , 104 ). Borrowing techniques from dialectical behavior therapy could establish additional tools that help patients and therapists work together to address narcissistic reactions during treatment ( 54 ). A third limitation concerns the possibility that self-esteem dysregulation may only be one component of NPD, and full treatment of this disorder could require additional interventions. Other important future directions include more closely connecting the model proposed here to classic studies of self-esteem and its development ( 4 , 5 , 13 , 14 , 20 , 105 – 108 ), investigating the utility of CBT-adjacent techniques such as motivational interviewing and mindfulness-based techniques in treating narcissistic dysregulation ( 109 , 110 ), and charting how self-esteem dysregulation develops within an individual across the lifespan ( 106 , 111 – 113 ).

In all, a cognitive-behavioral formulation of narcissistic self-esteem dysregulation could help patients diagnosed as having NPD change underlying beliefs and come to greater intrapersonal and interpersonal functioning. This model may be general enough to address transdiagnostic issues with self-esteem dysregulation, but additional clinical and empirical research are needed.

The findings in this manuscript were presented in part at the annual meeting of the American Psychiatric Association, May 18–22, 2019, San Francisco; and at the 17th World Congress of the International Society for the Study of Personality Disorders, October 11–13, 2021, Oslo, Norway.

Dr. Nook serves on the scientific advisory board of Walden, Inc. Dr. Choi-Kain receives book royalties from Springer Publishing and the American Psychiatric Association. The other authors report no financial relationships with commercial interests.

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• Narcissistic personality disorder
• cognitive-behavioral therapy
• self-esteem
• exposure therapy
• core beliefs
• cognitive therapy

New Insights Into Narcissistic Personality Disorder

Despite its survival and final inclusion in DSM-5, narcissistic personality disorder remains a controversial diagnosis. Here: perspectives on diagnosis, treatment, and prognosis.

Despite its survival and final inclusion in DSM-5, narcissistic personality disorder remains a controversial diagnosis. With a lifetime prevalence of 6.2%, it is less frequently identified in psychiatric settings but more often seen in private practice and applied to higher-functioning patients. 1,2 Conceptualizations and diagnostic definitions of narcissistic personality disorder have primarily focused on the more strikingly provocative, self-enhancing, entitled interpersonal behaviors and attitudes that tend to capture the attention of clinicians rather than on the patient’s underlying, internal struggles. This has contributed to making the diagnosis more judgmental rather than informative.

Advances in understanding narcissism

One of the major advances in recent clinical and empirical studies of narcissistic personality disorder is the recognition of co-occurring vulnerability (eg, insecurity, inferiority, fragility) that accompanies emotion dysregulation. 3 Similarly, the proposed hybrid model for personality disorders in DSM-5, which includes both dimensions and central traits, incorporates evaluations of level of functioning, as well as of sense of identity, fluctuations in self- and self-esteem regulation, and empathic capability.

Research in social and personality psychology has added significantly to our general understanding of narcissism. Nevertheless, research on narcissistic psychopathology is still sparse, mainly because of low societal urgency and health costs. Signs of narcissistic personality disorder are often more noticeable within organizational, social, family, and legal or forensic settings. Patients with this personality tend to seek treatment when they are facing serious ultimatums, failures, losses, or other consequential realizations. When in treatment, they are known for their reluctance, negative therapeutic reactions, and early dropout.

Narcissistic personality disorder is often comorbid with other psychiatric disorders for which treatment is sought. However, when such conditions are present, especially substance use disorder, bipolar disorder, eating disorder, or MDD, the clinical indications of pathological narcissism in the initial psychiatric evaluation and treatment planning are likely to be less noticeable or ignored. The underlying contribution of narcissistic personality functioning to a psychiatric disorder may be totally unrecognized; this prevents remission and contributes to relapses and refusal to follow psychiatric treatment recommendations.

The nature of narcissism and its application to psychopathology

Narcissism ranges from healthy and normal to pathological and severely malignant. It is closely related to regulation of self-esteem and emotions and to a sense of control and competence. Narcissism can be a motivating factor and can contribute to exceptional and remarkable accomplishments in higher-functioning people, even when it co-occurs with pathological narcissistic traits and dimensions. It is important to recognize not only the range of pathological narcissistic functioning (ie, self-enhanced/grandiose and vulnerable/insecure), but also the areas or context of the patient’s sense of agency with competence and abilities.

When treating a patient with narcissistic personality disorder , clinicians tend to assume that competence, self-esteem, and positive interpersonal interactions are deceptive “cover-ups” or “defenses” against more severe narcissistic traits, vulnerability, or the “true self.” The patient’s mistrust, negative reactivity, and treatment discontinuation are often caused by such inferences made early in treatment. An alternative clinical approach, both in evaluation and treatment, is to encourage and collaboratively explore the patient’s own accounts of problems and experiences-and especially of fluctuations in functioning, self-esteem, identity, and interpersonal interactions. The aim is to establish a shared agreement regarding the patient’s narcissistic psychopathology and its interaction with self-esteem and interpersonal functioning.

CASE VIGNETTE 1

Mr S, an engineer in a high-tech company, describes his struggle with insecurity in certain interpersonal interactions and social contexts, especially when they involve upper management and competitive colleagues. In these situations, he begins to shake, lose cognitive flexibility, and is unable to access words and expressions. He has been struggling with this since elementary school when he had teachers who scolded him when he could not correctly answer questions, and his parents had forcefully demanded that he “suck it up” and do his best.

Mr S is perceived by his peers, friends, and family as a high-achieving, stoic, critical, demanding man who can easily make others feel insecure or even resentful. Mr S was forced to seek treatment because of his increasing alcohol abuse, which was discovered by his colleagues and immediate supervisor. For many years he had engaged in hidden, controlled but gradually increasing alcohol consumption to manage stress, insecurity, and even fear in interpersonal interactions, both at work and with his wife and son.

This vignette highlights a multifaceted interactional pattern between narcissistic personality functioning and substance use disorder, competence and fragility, internal vulnerability and external self-enhancement. Obviously, Mr S’s substance use served the function of regulating insecurity and numbing intense reactions and emotions, especially in interpersonal contexts. The aim in treatment is to engage and balance Mr S’s abilities and self-esteem, which are related to his competence and commitment, with a gradual processing of his experiences of insecurity, loss of competence, and vulnerability.

Attachment patterns in narcissistic personality disorder

Pathological narcissism and narcissistic personality disorder primarily include avoidant, preoccupied, dismissive, and “cannot classify” interactive patterns. 4 The intense preoccupation of patients with negativity, blame, and criticism, as well as their engagement in a range of strategies to manipulate, avoid, and dismiss both the clinician and certain people or contexts in their lives can contribute to stalemates, misguided interpretations, and negative enactment.

CASE VIGNETTE 2

Ms G, an intelligent woman in her mid-20s, is an inpatient in an eating disorder program. Many of the sessions with her psychotherapist are spent complaining about program conditions and the way staff and other patients treat her and making various demands (eg, need for individual attention, different treatment modalities). She also feels that the other patients get away with inappropriate behavior without consequences. When her treatment team accedes to her requests, she dismisses them and always finds faults, misguided intentions, or unacceptable conditions. She perceives efforts to help her as being detrimental to her well-being.

She feels increasingly detached and isolated in the program and begins to express sadness and crying in addition to anger and complaints. The therapist attends to her negativity. Ms G is encouraged to explore past interpersonal experiences and to talk about her sadness. She begins to give more coherent descriptions of her mother’s early death and subsequently growing up with her father. She describes numerous subtle but nevertheless challenging experiences, such as her father’s inattention alternating with intense critical responses to her behavior as well as his involvement with different girlfriends that left her feeling overpowered, unseen, and nonexistent.

Her severe eating disorder became a way for Ms G to regulate anger, to take control and gain power, and to invest in her own identity and desired self-image. Once she was able to access her underlying sadness and describe her deeply rooted and previously nonverbalized emotional experiences, she became more actively involved in her treatment. She began to eat and started engaging with some of the other patients, and she began to outline goals for her future.

This vignette demonstrates attachment patterns that can unfold and dominate the therapeutic alliance during the treatment of a patient with a co-occurring eating disorder and pathological narcissism/narcissistic personality disorder. The systematic exploration of underlying experiences and psychological trauma that contribute to reactivity and self-enhancement, as well as to dismissive, avoidant, and preoccupied interactive patterns, can alter narcissistic functioning.

The underlying contribution of narcissistic personality functioning to a psychiatric disorder may be totally unrecognized; this prevents remission and contributes to relapses and refusal to follow psychiatric treatment recommendations.

Compromised empathy

Recent studies especially in the field of neuroscience have contributed to significant reconceptualization of empathy. 5 Identified in terms of ability to understand, process, and share the emotional state and experiences of others, empathic engagement depends on both emotional contagion and cognitive theory of mind, as well as on self-regulatory processes (emotions and self-esteem), motivation, and social interpersonal skills and decisions. DSM-5 conceptualizes empathy as a dimension of personality functioning related to comprehension and appreciation of the experiences and motivations of others, tolerance of differing perspectives, and understanding of the effects of one’s behavior on others.

Clinically defined, empathy is not static; it fluctuates and is affected by a range of contextual as well as emotional, interpersonal, and neuropsychological functions. Studies have found empathic ability in narcissistic personality disorder to be compromised and fluctuating, influenced by the interaction between deficits, capabilities, and motivation. 6 More specifically, patients with narcissistic personality disorder have intact cognitive empathic ability and can identify with thoughts, feelings, and intentions of others. However, their capacity for emotional empathy is compromised, especially their ability to care about and share feelings of others.

CASE VIGNETTE 3

Ms F, a professional woman and single mother of an 8-year-old son, describes a very emotional situation at work. The young daughter of one of her colleagues had lost her battle with cancer. Everyone in the department was emotionally affected by this tragic event and engaged in various ways to console their grieving colleague. Ms F described the situation as unbearable. She was noticeably upset and frustrated as she complained about the emotional reactions of her colleagues-she felt overwhelmed and had to leave the office.

Ms F also thought that this emotional outpouring was interfering with work and misdirected attention from an important project with a looming deadline that she was in charge of. From her perspective, successfully meeting the deadline was crucial for her upcoming promotion.

The therapist begins by validating Ms F’s challenges and viewpoint and encourages her to further describe her experiences. Ms F shifts mood and perspective and says, “Don’t take me wrong, I realize that my colleague has suffered a terrible loss, and I feel for her. I signed the condolence card and donated money, but I can’t stand all these feelings-I can’t hug her and let her cry on my shoulder the way everyone else is doing.” After a moment of silence and further consideration, Ms F says, “This whole situation reminds me of when my sister suddenly died when I was 8 years old. It was a terrible event, especially for my mother, and I was told to be strong and not show any feelings. I am also afraid of losing my son . . . this whole event just became too personal.”

This vignette clarifies a range of empathic functioning, especially with regards to emotion regulation. The patient’s initial self-enhancement with immediate concerns about her own position and intense negative dismissive reactions toward her colleagues gradually tapered down as her ability for cognitive empathic understanding and concern unfolded. Furthermore, her experiences of loss and accompanying family reactions, as well as her fear of facing a similar loss, interfered with her processing of the present event.

Perspectives on treatment and prognosis

The major shift in treatment of narcissistic personality disorder occurred in the 1960s with the pioneering contributions of Heinz Kohut and Otto Kernberg, who both claimed, although with radically different approaches, that narcissistic personality disorder was treatable with psychoanalytic psychotherapy. Since then, additional treatment modalities have focused on narcissistic personality disorder-in particular transference-focused, metacognitive, and schema-focused therapies. 7-9

Patients with NPD have intact cognitive empathic ability and can identify with thoughts, feelings, and intentions of others. However, their capacity for emotional empathy is compromised.

Comorbid conditions such as mood, anxiety, and impulsivity can be treated with psychopharmacology, but there are no psychotropic medications indicated for narcissistic personality disorder. Recent research on emotion processing and regulation has contributed to our understanding of the complex interaction between narcissistic hypersensitivity and reactivity-often hidden but serving as underpinnings for more overt self-enhancing, dismissive, or avoidant interpersonal patterns. 10-13

Collaborative exploratory strategies that focus on identifying and unfolding these very individual patterns need to be considered when making treatment decisions. Alliance building and engaging the patient’s sense of agency and reflective ability are essential for change in pathological narcissism. The prognosis for narcissistic personality disorder is relative to the diagnostic definition in terms of traits versus dimensions. A recent study found a 2-year remission rate of 52.5% but high dimensional stability. 14 This finding suggests both short-term context-dependent as well as long-term enduring patterns of narcissistic personality disorder. Differentiating these patterns and identifying and applying suitable and optimal treatment strategies are still works in progress.

Disclosures:

Dr Ronningstam is Associate Professor (PT) at Harvard Medical School in Boston and Clinical Psychologist at McLean Hospital in Belmont, MA. She reports no conflicts of interest concerning the subject matter of this article.

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Implications of Narcissistic Personality Disorder on Organizational Resilience

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In the Fifth Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association, narcissistic personality disorder is characterized by having feelings of self-importance, seeking for admiration, and lacking empathy. These traits map well into qualities of leadership such as having vision, having high achievement, and being able to make hard decisions. Unfortunately, narcissism often carries with it a number of negative traits such as manipulation or subversion of individuals, ethical lapses, and a need for constant change. On an organizational level, these traits may serve to undermine workers and the workplace, causing considerable damage in their wake and leaving personnel feeling helpless to intervene. This paper reviews an anonymized organizational case study of narcissistic personality disorder at a university. The dysfunction caused by a narcissistic leader directly led to the collapse of a program at the university, unusually high levels of attrition, and a diminished institutional reputation. This paper considers the implications of opportunistic leadership in eroding organizational resilience. Current research models focus on many of the factors that may erode organizational resilience, but they overlook the internal threat posed by narcissistic leaders. This paper reviews opportunities to consider narcissism as a causal factor in organizational resilience and human reliability analysis.

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Boring, R.L. (2020). Implications of Narcissistic Personality Disorder on Organizational Resilience. In: Arezes, P., Boring, R. (eds) Advances in Safety Management and Human Performance. AHFE 2020. Advances in Intelligent Systems and Computing, vol 1204. Springer, Cham. https://doi.org/10.1007/978-3-030-50946-0_35

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6.110: Narcissistic Personality Disorder

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Name: Jenna Maroney

Source: 30 Rock (Television series, mid 2000s)

Background Information

Jenna Marony is a forty-three year old woman, who was born Ystrepa Grokovitz on February 24, 1969. She grew up in Bakersfield, CA. Her father, was a burger server in suburban Santa Barbara. He dumped Jenna’s mother, a dental hygienist, for another woman. Jenna still says she will “always be his little girl.” After being spurned, Jenna’s mother made her sit on every mall Santa’s lap in Bakersfield in an attempt to find him. Jenna has a sister who urinated in one of Jenna’s eyes when she was little, which causes it to not open all the way. Another sister is deceased. She did not get along with her half-sister, Courtney, who is now deceased. Upon hearing of her sister’s demise, Jenna showed no obvious signs of sorrow or grief. Jenna also has a niece, who draws pictures of her Auntie Jenna. Jenna finds the pictures to be offensive, when in fact they are just childlike renderings of Jenna.

During Jenna’s teen years, her mother moved what family she had left from California to Florida. Jenna attended high school on a boat, which has subsequently sunk. At the age of 16, Jenna was engaged to a congressman. She has also reportedly dated O.J. Simpson, a music producer, a sniper, a mob boss, and hinted at having been in a three-way relationship with Rosanne and Tom Arnold. Jenna’s started singing at a young age, as a distraction for her mom, who was busy shoplifting. Jenna went on to study voice at Northwestern University and also at the Royal Tampa Academy of Dramatic Tricks, where she majored in playing prom queens and murdered runaways. She has been in various films and commercial, and is currently employed as an actress on a television series.

There is no history of substance use, however, there is a history of binge eating, but the episode was brief, and Jenna’s eating habits have since returned to normal. Jenna is in good health, with no reported concerns.

Jenna seems to have coped with her life difficulties by becoming the “center of attention,” and the center of her own universe. Abandoned by her father and used by her mother as a decoy, Jenna possibly feels unloved and rejected. Jenna’s inability to empathize with others and sustain lasting relationships with are major weaknesses. She is constantly battling with someone, whether it be a co-worker, a friend or a family member. Currently, Jenna is involved with a transvestite who dresses as Jenna. In fact, Jenna met her lover while participating in a Jenna Maroney Look-Alike Contest, in which Jenna herself only placed fourth. Her new lover won the contest, and they have been intimate since that time.

Description of the Problem

Jenna does not feel she has any problems, other than not receiving the attention and recognition she feels she deserves. Her achievements are not commensurate with her desire to be “worshipped,” and adored. Jenna feels she is entitled to special treatment and when this fails to occur within her career or social life, she becomes explosive and stubborn. She has an excessive need for admiration, as evidenced by her choice of careers. She seems to have no empathy regarding others, and on the rare occasions empathy is displayed by Jenna, it is not genuine empathy, but a means to an end. In other words, she fakes empathy to manipulate others, or for personal gain. Jenna repeatedly poisoned a co-worker in the hopes of dating one of the “hot” EMT workers who came to the rescue. Jenna is severely jealous of her co-star in her current television series, and is constantly looking for ways to undermine him. She dreams of unparalleled success and believes she is the most beautiful, talented woman to grace this planet. While Jenna does not see this as a problem, the rest of society fails to agree with her assessment of herself, and this causes much frustration for Jenna. Jenna reacts very unfavorably to even the slightest criticism, as she believes herself to be perfect and unique. If she is criticized, she feels that the person doing the critique, “just doesn’t understand her,” because they are not as special and wonderful as she.

Jenna best fits the diagnostic category of Narcissistic Personality Disorder (301.81)

• has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
• is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love (perfect marriage to the perfect spouse)
• believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
• requires excessive admiration
• has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations (“You owe me because I’m that good”)
• is inter-personally exploitative, i.e., takes advantage of others to achieve his or her own ends
• lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
• is often envious of others or believes that others are envious of him or her
• shows arrogant, haughty behaviors or attitudes
• history of intense but short-term relationships with others; inability to make or sustain genuinely intimate relationships
• a tendency to be attracted to leadership or high-profile positions or occupations
• a pattern of alternating between unrealistic idealization of others and equally unrealistic devaluation of them
• assessment of others in terms of usefulness
• a need to be the center of attention or admiration in a working group or social situation
• hypersensitivity to criticism, however mild, or rejection from others
• an unstable view of the self that fluctuates between extremes of self-praise and self-contempt
• preoccupation with outward appearance, “image,” or public opinion rather than inner reality
• painful emotions based on shame (dislike of who one is) rather than guilt (regret for what one has done)

Jenna qualifies for almost every single diagnostic criteria, as outlined in the Description of the Problem and her Background information. There is some overlap with Histrionic Personality Disorder, as Jenna does frequently use her sexuality to gain her desires, however, she fits more of the Narcissistic criteria than the HPD criterion.

Accuracy of Portrayal

The portrayal of narcissism in this character is fairly accurate, although there is some overlap with Histrionic Personality Disorder. One of the deciding factors whether this was NPD or HPD was the fact that Jenna falls in love with a man who dresses as her. Narcissus was also in love with himself and was forever doomed to gaze upon his reflection in a pool of water, until he died. It is said as his boat crossed over into the afterlife, he leaned over to catch on last glimpse of himself in the water. This is the epitome of Jenna. While more males than females are diagnosed with NPD, (7% for males and 4 % for females), Jenna is a prime example of a female narcissist.

Narcissists rarely seek treatment, as their perception is that they are “better” than everyone else. If a narcissist does enter treatment, psychotherapy is the recommended course of treatment, and perhaps some group therapy. If group therapy is utilized, clear boundaries should be set as to respecting other people in the group. Prognosis poor.

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What Does Research Say About Older Adult Narcissists?

Never assume that giving a narcissist what they want is going to satisfy them..

Posted April 12, 2024 | Reviewed by Tyler Woods

• What Is Narcissism?
• Find a counsellor who understands narcissism.
• Personality disorders do not always wane as people age.
• Older adults with NPD are more likely to communicate with aggression and disagreeableness.
• Avoid emotional overinvolvement as that only weighs you down further.

We might want to believe that as people age, they grow in their wisdom , their kindness, and their interest in giving back to others. While this is true for many older adults, individuals who were diagnosed with personality disorders earlier in their lives are likely to carry those traits into later adulthood. In fact, one study (Penders et al., 2020) indicated that as many as 15 percent of older adults living within their residential communities have diagnosable personality disorders, and around 58 percent of those in nursing homes do. Not only are professionals being faced with growing challenges in treating these individuals, but families and children of these older adults are faced with increasing challenges, as well.

While research suggests that older adult men are more likely than women to have a personality disorder diagnosis (Treagust et al., 2022), women are more likely to have other mental health diagnoses. Narcissistic Personality Disorder (NPD) is more common among men, and it appears that it arises as a product of early interpersonal relationships and temperament— anger levels in youth are related to the development of NPD (Lenzenweger, 2023).

Recognizing that narcissists have overly high estimations of their ability, entitlement, and status, it makes sense that they may react with extreme anger when they are thwarted or denied what they feel they are due. Anger and a desire to lash out are frequent reactions when they feel they have been disrespected, not given the credit they believe they deserve, or their demands have gone unmet.

The Negativity of Older Adult Narcissists

As people age, the frequency of social interactions often decreases, which can lead to loneliness . However, while most older adults experience less loneliness when they engage with other people, narcissists do not experience a similar mood shift (Zhang et al., 2020). Older narcissists don’t value social interactions in the same way—nor do they feel better for having spent time with others. In another study, Zhang et al. (2022) found that the verbal expressions used by older narcissists are markedly different from their peers. They not only talk more, but they also swear more, and use more aggressive and less agreeable language.

Caregiver or Child of the Narcissist: It’s Never Easy

While growing up with a narcissistic parent can be unbelievably challenging, the hope that you may one day escape and live your own life may be dashed when your older parent needs your care or support. Unfortunately, narcissistic behavior and the myopic, self-centered perspective can seemingly grow in magnitude as an older adult diminishes in other abilities. They may make everything a “life or death” situation as they hound you into responding to their needs and their whims. They may blame you for poor decisions they’ve made, missed opportunities, and lash out at you because of their failing health or reduced capacity.

What Is the Fallout From Caregiving for a Narcissist?

If you’re caring for a narcissist and can’t understand why you have it so much harder than others who care for someone, you might be relieved to know that research (Day et al., 2020) shows that your load is greater than many others. In fact, caring for someone with NPD is harder than if they had some other serious mental illness. It carries more of a burden and diminishes well-being, yet it is unlikely to increase feelings of grief or sympathy for the person with NPD who acts out in aggressive ways.

How to Cope?

Perhaps the most important rule to remember when caring for an older adult narcissist is to not get overly emotionally involved and not to overly engage in criticism. Both of these maladaptive coping styles negatively affect the person trying to cope. Recognizing the limits of what a caregiver can accomplish in terms of rehabilitating a narcissist is a gift you can give yourself. Getting overly involved in their symptomology doesn’t help anyone, and being highly critical of them is unlikely to change their behavior.

• Don’t assume that giving a narcissist what they want is going to satisfy them. Narcissists are never satisfied. There is always something else they are going to demand, just as you’ve capitulated on everything they’d asked for already.
• Grant yourself grace. Recognize that caring for a narcissist is more draining than caring for someone with other mental disorders. It’s normal to feel overwhelmed and angry sometimes.
• Don’t allow your negative feelings to consume you. Acknowledge them and let them pass through you. Don’t allow yourself to ruminate on things—that leads to feelings of depression and only makes you feel less able to manage.
• Build in “escape time” and “break time.” When we know that there’s a light at the end of the tunnel, even if it’s just a few minutes standing on the porch soaking in the sunshine, it makes the hard things more bearable.
• Create and maintain boundaries to protect your internal and external resources. Just because someone demands something of you doesn’t mean you have to provide it—whether it is tangible or intangible resources.
• Don’t feel guilty about failing to make a narcissist happy. There is nothing that can bring a narcissist lasting satisfaction except the continued suffering of others as they work to fill the narcissist’s needs.
• Join a support group. Knowing that others share the struggles that you are facing can normalize your experiences. It helps to hear others’ stories and how they’ve managed similar challenges.
• Reach out for professional support. Talking out your feelings and getting an objective perspective can be freeing—as can discussing complicated emotions, accepting one’s limits, looking at options, and learning new coping strategies.

To find a therapist near you, visit the Psychology Today Therapy Directory .

Lenzenweger, M. F. (2023). Proximal Processes, Temperament, and Pathological Narcissism: An Empirical Exploration from the Longitudinal Study of Personality Disorders. Psychopathology , 56 (1-2), 41-51.

Penders, K. A., Peeters, I. G., Metsemakers, J. F., & Van Alphen, S. P. (2020). Personality disorders in older adults: A review of epidemiology, assessment, and treatment. Current psychiatry reports , 22 , 1-14.

Treagust, N., Sidhom, E., Lewis, J., Denman, C., Knutson, O., & Underwood, B. R. (2022). The epidemiology and clinical features of personality disorders in later life; a study of secondary care data. International Journal of Geriatric Psychiatry , 37 (12).

Zhang, S., Gao, S., & Fingerman, K. (2022). DETECTING NARCISSISM FROM DAILY LANGUAGE USE: A MACHINE LEARNING APPROACH. Innovation in Aging , 6 (Supplement_1), 611-612.

Zhang, S., Ng, Y. T., & Fingerman, K. (2020). Narcissism, Social Encounters, and Mood in Late Life. Innovation in Aging , 4 (Supplement_1), 388-388.

Suzanne Degges-White, Ph.D. , is a licensed counselor and professor at Northern Illinois University.

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Clinician perception of pathological narcissism in females: a vignette-based study

1 Department of Psychology, City, University of London, London, United Kingdom

Rory MacLean

2 Department of Psychology, Edinburgh Napier University, Edinburgh, United Kingdom

Kathy Charles

3 Centre for Academic Development and Quality, Nottingham Trent University, Nottingham, United Kingdom

Associated Data

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

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.

Introduction

The issue of gender bias across the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) personality disorder criteria in general, and Narcissistic Personality Disorder (NPD) in particular, is controversial and has been widely debated. Compared to other diagnostic manuals that integrates grandiose and vulnerable expressions of NPD (e.g., the Psychodynamic Diagnostic Manual-Second Edition; PDM-2; Lingiardi and McWilliams, 2017 ), NPD as codified in the DSM-5 predominantly captures overt grandiosity, including symptoms such as interpersonal exploitation, entitlement, exhibitionism, lack of empathy, and self-serving fantasies of omnipotence. The DSM-5 reports that up to 75% of those diagnosed with NPD are males ( American Psychiatric Association, 2013 ), which suggests that the representation of narcissism (NPD DSM-5) may only apply marginally to females, due to its overemphasis on capturing grandiose themes at the expense of vulnerable variants of the disorder ( Levy et al., 2011 ). Vulnerable narcissism includes elements of shyness, hypersensitivity, rumination, shame, and low self-esteem ( Pincus et al., 2009 ). The gender bias in the conceptualization of narcissism was recognized by early theorists who contested that clinical observations made by Kernberg (1975) and Kohut (1977) have emerged from patriarchal and phallocentric narratives that overemphasize masculinity and the male syndrome, whereas feminine voices are demoted ( Akhtar and Thomson, 1982 ; Philipson, 1985 ; Richman and Flaherty, 1988 ).

For instance, Philipson (1985) stated that Kernberg’s (1975) and Kohut’s (1977) discoveries derived from 29 clinical case studies of patients exhibiting NPD traits, of which only five cases depicted women. The disproportionate sample of male patients was noteworthy due to the clinical population consisting predominantly of female psychiatric patients ( Philipson, 1985 ). In other words, such figures preclude the assumption that the gender ratio is an artifact of sampling bias in the psychiatric setting, and, in turn, support the contention that narcissistic pathology as captured in the DSM-5 is understood primarily, if not exclusively, through the perspective of males. Indeed, grandiose features of narcissism have been closely linked to male socialization characteristics, including displays of physical aggression, authority, and an excessive need for power and status ( Corry et al., 2008 ; Grijalva et al., 2014 ). Whilst females are less likely to exhibit overt “stereotypical” narcissistic features, their expression of narcissistic pathology may resemble more feminine qualities associated with vulnerable features, such as shame, low self-esteem, and inhibition ( Green et al., 2021 ). Although some research reports no gender differences on vulnerable narcissism measures (e.g., Grijalva et al., 2014 ), other reviews report a higher female preponderance (see Green et al., 2021 ), albeit the effect size of these gender disparities range from small to medium (e.g., Pincus et al., 2009 ; Wright et al., 2010 ).

The extent to which the construct and prevalence of NPD is, in fact, gender-biased has significant implications for the diagnosis and treatment across gender. Clinical studies have found that clinicians may be more likely to treat patients who present narcissistic vulnerability, compared to those who present narcissistic grandiosity. This is because of the increased compliance with treatment associated with patients presenting narcissistic vulnerability, compared to patients presenting narcissistic grandiosity ( Pincus et al., 2009 ; Ellison et al., 2013 ). These findings, however, convey a mismatch between the presentation of grandiose narcissism as captured by the DSM, which tends to be more prevalent in men, and vulnerable narcissism, which is currently barely considered by the DSM and tends to be more prevalent in women ( Green et al., 2021 ). This is particularly concerning in light of the potential misdiagnosis of vulnerable narcissism, given its overlap with BPD ( Miller et al., 2010 ; Euler et al., 2018 ) and avoidant and dependent personality disorders ( Dickinson and Pincus, 2003 ; Miller et al., 2014 ).

Gender bias in clinical judgment of narcissistic personality disorder

The clinical and empirical literature has consistently established a significant link between the male gender and NPD ( Lindsay et al., 2000 ; Karterud et al., 2011 ; Hoertel et al., 2018 ). These findings are commonly grounded in the assumption that the criteria of NPD are gender-biased, where males and females are traditionally considered to manifest the disorder differently due to gender-related symptomatology. Independent of any actual differences in classifications of personality disorders (PDs) between males and females, misdiagnoses may partly contribute to the differential prevalence rates of PDs observed in the DSM-5 ( Schulte and Habel, 2018 ). Research has argued that vulnerable narcissism may be overlooked or misdiagnosed as BPD in female patients particularly, whereas males are more prone to be diagnosed with NPD due to their overt grandiose presentation of narcissism ( Euler et al., 2018 ). This is significant as females are more prone to seek treatment than males ( Skodol and Bender, 2003 ), and clinicians are more likely to treat patients with NPD when they are in a vulnerable state ( Ellison et al., 2013 ). These findings reflect the preponderance of females diagnosed with BPD in clinical settings, as the latter does not resemble the balanced gender ratio found in epidemiological cohorts ( Paris et al., 2013 ).

Providing further support for the above theorizations, a research study by Anderson et al. (2001) found that clinicians diagnosed narcissistic and antisocial PDs more frequently in men, whereas women were more likely to be diagnosed with borderline, dependent, and histrionic PDs. The authors noted that clinicians did not consider the diagnostic criteria to be more (or less) maladaptive or pathological for a man than for a woman. Rather, clinicians perceived men to be more physically aggressive and more likely to exhibit a grandiose self-image than women. This invites the possibility that the differential prevalence rates in diagnoses may be partly due to gender stereotyping. It must be noted, however, that longstanding gender differences have been shown to be rooted in biological differences where men are generally more physically aggressive than women (e.g., Skodol and Bender, 2003 ; Schulte and Habel, 2018 ).

Interestingly, research has revealed that sex bias 1 in diagnosis may, in part, occur due to the ambiguity of the case. Braamhorst et al. (2015) presented trainee clinicians with hypothetical case vignettes containing an ambiguous case (which contained subthreshold features of both NPD and BPD) and a non-ambiguous case (which contained subthreshold features of either NPD or BPD). The authors distinguished two underlying mechanisms for sex bias: gender stereotyping and actual base rate variations (differences observed in males and females due to factors other than gender stereotypes). Results showed that there was no effect of sex of patient for non-ambiguous vignettes; however, when the case was ambiguous, participants diagnosed BPD more often in females than in males, and NPD more often in males than in females. The authors concluded that when there is ambiguity in the classification of PD, sex bias is present and more likely to be influenced by base-rate variation than gender stereotyping. An acknowledged limitation and suggestion for future research pertained to the inclusion of participant characteristics (e.g., years of experience, type of psychotherapy training) for a finer-grained analysis.

Treatment of narcissistic personality disorder

The descriptive characteristics of narcissism and diagnostic criteria that best exemplify the construct have been much debated. These disparities have been poorly calibrated across the psychiatry, clinical, and social/personality literature, reflecting enduring disagreement among clinicians and experts with regard to the central features of narcissism ( Green et al., 2021 ). For instance, research from the social/personality literature questions the notion that narcissistic grandiosity and vulnerability “co-exist” (e.g., Miller et al., 2018 ), whereas the clinical literature suggests narcissistic individuals oscillate between the two dimensions ( Cain et al., 2008 ). Crucially, although both experts in the social/personality field and clinicians generally believe that the grandiose features are central to narcissism, clinicians also consider concurrent vulnerability to be a defining feature of the construct ( Ackerman et al., 2017 ). Despite these differences in opinions, Ackerman et al. (2017) found that clinicians have little to no consensus in their views regarding the centrality of vulnerable characteristics in NPD, perhaps reflecting different therapy orientations shaping clinicians’ understanding of narcissism and the related central pathognomonic features (i.e., characteristics of a particular condition).

The efficacy of psychotherapeutic approaches and evidenced-based treatments for NPD is limited ( Caligor et al., 2015 ). It has been argued that, in the absence of empirically supported treatments for NPD, it is common practice to utilize other effective treatments from “near-neighbor” disorders, such as BPD ( Kealy et al., 2017 ). Indeed, researchers have posited that treatments designed explicitly for BPD patients, such as dialectical behavioral therapy, might be usefully employed for individuals with vulnerable narcissism, given their similar nomological networks ( Kaufman et al., 2018 ). In the case of individuals with grandiose narcissism, researchers have argued that these individuals are likely to require different therapeutic approaches compared to their vulnerable counterparts ( Ogrodniczuk et al., 2009 ). However, in a study gathering clinicians’ preferred therapy for patients with NPD, grandiose and vulnerable presentations of narcissism were associated with the same treatment approach ( Kealy et al., 2017 ).

The lack of clarity regarding preferred treatment choices for patients with grandiose and vulnerable expressions on the one hand, and research which demonstrates that clinicians’ therapeutic orientations can significantly affect their diagnostic judgments ( Woodward et al., 2009 ) on the other hand, suggests that exploring clinicians’ preferred therapy in practice could shed light on how clinicians conceive of, and treat, narcissistic pathology. For instance, compared to the DSM-5 which emphasizes grandiosity, other diagnostic manuals such as the PDM-2 ( Lingiardi and McWilliams, 2017 ) originate from psychodynamic conceptualizations of NPD which captures both grandiose and vulnerable features. This accentuates the importance of investigating the extent to which therapy modality affects diagnostic outcome.

The present study

The current study extends the literature through exploring the implications of clinicians’ perceptions of pathological narcissism in clinical case vignettes, particularly in hypothetical female patients. Specifically, this study aims to investigate the PD diagnoses commonly leveled at hypothetical patients who present vulnerable narcissism traits, and whether clinician and patient gender play a role. The study also examines the extent to which clinicians’ preferred therapy approach and length of experience in practice influences the likelihood of diagnosis in cases with vulnerable narcissism symptomatology. Vignettes depicting grandiose features of narcissism will also be included to further explore gender differences in clinical diagnosis of NPD. These factors are explored in an online, vignette-based study with trainee and practicing clinicians.

To the knowledge of the author, this is the first study to explore clinicians’ diagnostic ratings of cases with vulnerable narcissism symptoms. As such, the present study is designed as an exploratory step toward building a cohesive and coherent understanding of the assessment, diagnosis, and treatment of narcissism, particularly in women.

Research questions

(1). What are the common diagnostic labels given by clinicians to hypothetical patients who present symptoms of vulnerable narcissism?

(2). To what extent do clinician and patient gender influence clinicians’ diagnostic labels for cases with vulnerable narcissism symptomatology?

(3). To what extent do clinicians’ psychological therapy practices and years of experience influence diagnostic labels for cases with vulnerable narcissism symptomatology?

The current study is largely exploratory in nature and therefore offers no specific hypotheses except for the following:

Hypothesis 1 : When presented with a vulnerable narcissism vignette depicting a female patient, clinicians will provide significantly higher diagnostic ratings of borderline, dependent, and avoidant personality disorders compared to other DSM personality disorders. This assumption is based on previous research demonstrating an overlap between vulnerable narcissism and BPD (e.g., Miller and Campbell, 2008 ; Euler et al., 2018 ), avoidant and dependent PDs ( Dickinson and Pincus, 2003 ; Miller et al., 2014 ), and the observed gender bias pertaining to the overrepresentation of females in borderline and dependent PD diagnoses ( American Psychiatric Association, 2013 ; Paris et al., 2013 ; Euler et al., 2018 ).

Materials and methods

Design and participants.

This vignette study adopted a mixed experimental design. Independent variables were patient and clinician gender (male/female) and therapy approach (CBT/psychodynamic). The dependent variable was the likelihood of diagnosis given across a range of possible conditions. Correlational design was also employed to investigate the relationship between clinicians’ length of experience in practice and their likelihood of diagnosis given.

From the initial sample pool ( n = 197), 89 participants were excluded due to incomplete data. The final analysis was conducted using the remaining 108 participants. The sample comprised 79 females (73.1%) and 29 males (26.9%). The age range of participants was 22–61 years with a mean of 38.31 years (SD = 9.9).

Inclusion criteria were being over 18 years of age, being fluent in English, and either having undertaken clinical practice or being active in clinical practice. Participants were predominantly Caucasian ( n = 101), with three identified as South or East Asians, one identified as Middle Eastern, and the remaining two participants chose “mixed” or “other” for their ethnic status. Participants’ most recent qualifications were the following: Doctorate in Clinical Psychology ( n = 35), MSc degree in Clinical Psychology/Trainee Clinical Psychologist ( n = 17), Chartered Psychologist ( n = 16), and Licensed Psychotherapist ( n = 14). The remaining 26 participants did not indicate their qualifications, or their answers were ambiguous ( n = 3).

Additional descriptive information regarding clinicians’ length of experience in practice and current psychological therapy used in practice are displayed in Table 1 .

Participant demographics.

Dashes indicate no response.

Clinical case vignettes

The study used clinical case vignettes of hypothetical patients presenting prototypical expressions of vulnerable narcissism, grandiose narcissism, or panic disorder without personality pathology. The panic disorder vignette was utilized as a “distractor” condition to avoid priming clinicians toward any potential bias with regard to the aims of the current study (i.e., gender bias in personality disorders). For these purposes, the panic disorder vignette was not included in the main analyses of the current study.

The two narcissism vignettes and the panic disorder vignette were constructed by Kealy et al. (2017) . The narcissism vignettes were informed by the review of Cain et al. (2008) . Each vignette contained one hypothetical patient (with two versions: male and female), creating six different vignettes. Despite some male and female vignettes differing in line with gender role specific aspects, no significant clinical differences existed between them.

The research team and three highly experienced clinicians in the field of pathological narcissism and personality disorder reviewed these vignettes, which resulted in the following amendments: the male and female prototypes in the grandiose narcissism vignettes were markedly different in context, and in order to ensure consistency across all vignettes, one version of the vignette was used (with the gender inverted, thus creating male and female prototypes with identical context). The vulnerable narcissism and panic disorder vignettes were retained in their original versions.

An online study (using Qualtrics) was advertised via social network sites and e-mails were sent to clinical psychology committees and organizations to distribute the study to a broader sample of clinical psychologists. After giving informed consent, participants completed demographic questions and were then randomly assigned either three male vignettes or three female vignettes to avoid priming participants to gender bias.

Participants were presented with the three vignettes: vulnerable narcissism, grandiose narcissism, and panic disorder without personality pathology. After reading each vignette, participants indicated the likelihood of diagnosis for a range of personality disorders (PDs) on a 1 (very unlikely) to 8 (very likely) rating scale, on the basis of the available history. All the PDs in the DSM-5 were listed, in order to avoid priming participants to a particular diagnosis: paranoid PD, narcissistic PD, schizoid PD, antisocial PD, borderline PD, histrionic PD, avoidant PD, dependent PD, and obsessive-compulsive PD. The choice of “other” was included based on the following reason: first, given that vulnerable narcissism is not a separate PD diagnosis in the DSM-5, clinicians had the opportunity to elaborate their justification for classifying vulnerable narcissism, or any of the other vignettes presented, as a condition separate from the PDs listed. In cases where clinicians classified vulnerable narcissism as narcissistic PD, this was interpreted as clinicians perceiving narcissistic PD as being a condition that manifests both grandiose and vulnerable traits (see Ackerman et al., 2017 ), despite the emphasis on grandiosity in the DSM-5 classification of NPD. After rating the vignettes, participants were debriefed and thanked for their time.

Preliminary analyses

Preliminary analyses indicated violations of normality for the majority of variables, and data transformation did not correct the non-normality of data; thus, non-parametric tests were used. Due to multiple comparisons and tests being conducted, Type I error was controlled by a stricter alpha level of 0.01 for those cases where a Bonferroni correction had not already been applied.

Prior to exploring gender differences in diagnoses with vulnerable narcissism symptomatology, descriptive analyses were run for all vignettes to investigate the diagnoses commonly leveled at symptoms of vulnerable narcissism and grandiose narcissism. As seen in Figure 1 , the most frequently endorsed diagnoses to cases with vulnerable narcissism symptomatology were dependent, avoidant, and borderline PDs (as indicated by the median score). For cases with narcissistic PD symptomatology, Figure 1 show the preferred diagnosis of NPD as indicated by the median score. 2 As expected, clinicians’ median score was one across all PDs for the panic disorder without personality pathology vignette.

Clinicians’ likelihood of diagnosis across three conditions. PPD, paranoid PD; NPD, narcissistic PD; SPD, schizoid PD; ASPD, antisocial PD; BPD, borderline PD; HPD, histrionic PD; APD, avoidant PD; DPD, dependent PD; OCD, obsessive-compulsive PD.

Endorsement of diagnostic labels

Friedman’s repeated samples test was used to determine if there were any differences in the rating of the available diagnostic labels for the vulnerable narcissism vignette. The likelihood of diagnosis across conditions was the outcome variable, and the diagnostic label was entered as the independent variable. Tables 2 , ​ ,3 3 shows the Friedman’s repeated samples test for the vulnerable narcissism vignette in male and female clinicians, respectively.

Male clinicians’ likelihood of diagnosis in cases with vulnerable narcissism symptomatology.

Values in the lower part of the table present the test statistic = χ2. PPD, paranoid PD; NPD, narcissistic PD; SPD, schizoid PD; ASPD, antisocial PD; BPD, borderline PD; HPD, histrionic PD; APD, avoidant PD; DPD, dependent PD; OCD, obsessive-compulsive PD. * p < 0.05. ** p < 0.01. *** p < 0.001.

Female clinicians’ likelihood of diagnosis in cases with vulnerable narcissism symptomatology.

Values in the lower part of the table present the test statistic = χ2. PPD, paranoid PD; NPD, narcissistic PD; SPD, schizoid PD; ASPD, antisocial PD; BPD, borderline PD; HPD, histrionic PD; APD, avoidant PD; DPD, dependent PD; OCD, obsessive-compulsive PD. * p < 0.05. *** p < 0.001.

The Friedman test indicated a significant difference between the diagnoses attributed in the vulnerable narcissism vignette condition, for male clinicians: χ 2 (9) = 80.297, p < 0.001, and for female clinicians: χ 2 (9) = 266.793, p < 0.001. Dunn’s pairwise post hoc test with a Bonferroni correction applied showed that both male and female clinicians were significantly more likely to endorse the label of borderline PD compared to antisocial PD when presented with a vulnerable narcissism vignette. Male and female clinicians’ diagnosis of dependent PD was also significantly more likely endorsed compared to antisocial PD, schizoid PD, “other,” narcissistic PD, histrionic PD, and obsessive-compulsive disorder. Further, avoidant PD was significantly more likely diagnosed compared to antisocial PD, schizoid PD, “other,” narcissistic PD, and histrionic PD, for both male and female clinicians.

Clinicians gender bias in diagnoses for cases with vulnerable narcissism symptomatology

To investigate potential gender bias in diagnoses of cases with vulnerable narcissism symptomology, a Kruskal-Wallis test was conducted to explore whether there were differences in likelihood of diagnosis between the four groups: male clinician/male patient, male clinician/female patient, female clinician/male patient, and female clinician/female patient (see Table 4 ). The mean ranks were compared, rather than the medians, given that the distributions in each group were not the same as indicated by visual inspection of histograms and the Levene’s test.

Clinicians’ gender bias in diagnoses for cases with vulnerable narcissism symptomatology.

C, clinician; P, patient; PPD, paranoid PD; NPD, narcissistic PD; SPD, schizoid PD; ASPD, antisocial PD; BPD, borderline PD; HPD, histrionic PD; APD, avoidant PD; DPD, dependent PD; OCD, obsessive-compulsive PD. Dashes indicate no significant difference between groups. * p < 0.05, ** p < 0.01, *** p < 0.001.

The Kruskal–Wallis test showed a significant difference between the groups for the diagnosis of “other.” Dunn-Bonferroni post hoc pairwise comparisons indicated that male clinicians were significantly more likely to diagnose a male patient with vulnerable symptoms as “other,” compared to all other clinician/patient gender combinations. The results pertaining to the diagnosis of “other” were followed up with post hoc Mann–Whitney comparisons (see Tables 5 , ​ ,6). 6 ). As shown in Table 5 , male clinicians were significantly more likely to attribute a diagnosis of “other” and Obsessive compulsive disorder (OCD) when presented with a vulnerable narcissism vignette, compared to female clinicians. With regard to patient gender, Table 6 shows that female patients were significantly more likely to be diagnosed as BPD and OCD, compared to male patients in the vulnerable narcissism condition.

Mann–Whitney comparisons for participant gender in vulnerable narcissism condition.

PPD, paranoid PD; NPD, narcissistic PD; SPD, schizoid PD; ASPD, antisocial PD; BPD, borderline PD; HPD, histrionic PD; APD, avoidant PD; DPD, dependent PD; OCD, obsessive-compulsive PD. * p < 0.05, ** p < 0.01.

Mann–Whitney comparisons for patient gender in vulnerable narcissism condition.

PPD, paranoid PD; NPD, narcissistic PD; SPD, schizoid PD; ASPD, antisocial PD; BPD, borderline PD; HPD, histrionic PD; APD, avoidant PD; DPD, dependent PD; OCD, obsessive-compulsive PD. * p < 0.05.

Clinicians’ psychological therapy and years of experience

In order to investigate differences between clinicians’ main psychological therapeutic approach in practice, two groups were created based on the underlying conceptual foundation for their therapy: “Psychodynamic” (including participants who identified Psychodynamic psychotherapy or Interpersonal therapy as their main therapeutic approach) and “CBT” (including CBT and Mindfulness-based cognitive therapy); participants who selected other therapeutic approaches were not included (due to limited group sizes). Mann–Whitney tests were conducted to explore differences between clinicians’ underlying therapeutic approach and the likelihood of diagnosis given in the vulnerable narcissism condition (see Table 7 ). Clinicians with a psychodynamic approach were significantly more likely to diagnose vulnerable narcissism as narcissistic PD compared to those with a CBT approach. Clinicians with a psychodynamic approach were also significantly more likely to diagnose vulnerable narcissism as obsessive-compulsive disorder, compared to those with a CBT approach.

Mann–Whitney comparisons for clinicians’ therapy modalities in vulnerable narcissism condition.

PPD, paranoid PD; NPD, narcissistic PD; SPD, schizoid PD; ASPD, antisocial PD; BPD, borderline PD; HPD, histrionic PD; APD, avoidant PD; DPD, dependent PD; OCD, obsessive-compulsive PD. ** p < 0.01.

A Mann–Whitney test was conducted to explore these patterns in males and females separately. The only significant difference was found for female clinicians: females with a psychodynamic approach were significantly more likely to diagnose vulnerable narcissism as narcissistic PD compared to those with a CBT approach (see Supplementary material for these data).

Spearman’s rho was conducted to explore correlations between clinicians’ length of experience and the likelihood of the particular diagnosis given (see Table 8 ). Interestingly, length of experience was positively significantly correlated with attributing narcissistic PD diagnosis when presented with symptoms of vulnerable narcissism vignette. Conducting these separately for male and female clinicians revealed that this finding was only significant in females.

Spearman’s rho correlations in clinicians between length of experience and diagnosis in vulnerable narcissism condition.

The purpose of the current study was to explore the extent to which clinicians influence the diagnostic labels commonly attributed to cases with vulnerable narcissism symptomatology, particularly in hypothetical female patients. The role of clinicians’ gender, therapeutic orientations, and length of experience were examined given the potential they could influence such diagnostic labels on the one hand, and their relevance to the assessment and treatment of pathological narcissism in women on the other.

The hypothesis that the borderline, dependent, and avoidant PD diagnoses are most frequently endorsed when clinicians are presented with a female patient exhibiting vulnerable narcissism symptoms, compared to other DSM personality disorders, was supported. These findings resonate with previous research demonstrating an overlap between vulnerable narcissism and borderline PD ( Miller and Campbell, 2008 ; Euler et al., 2018 ), and avoidant and dependent PD ( Dickinson and Pincus, 2003 ; Miller et al., 2014 ). More importantly, the findings of this study also showed that, when presented with a vulnerable narcissism vignette, clinicians were significantly more likely to attribute a BPD diagnosis in female patients, compared to male patients. The current results provide implications for gender bias in the DSM in general, and for the assessment and treatment of vulnerable narcissism in particular. With regard to the former, the current findings suggest that the observed gender bias pertaining to the overrepresentation of females in borderline and dependent PD diagnoses ( American Psychiatric Association, 2013 ; Paris et al., 2013 ; Euler et al., 2018 ) may, in part, be attributed to how clinicians perceive narcissistic vulnerability symptoms in female patients. This is particularly significant considering previous research suggesting that females are more likely to seek treatment than males ( Skodol and Bender, 2003 ), and clinicians are more likely to treat patients who present narcissistic pathology of the vulnerable type ( Ellison et al., 2013 ), features which tend to be more prevalent in narcissistic females ( Green et al., 2021 ).

When presented with symptoms of vulnerable narcissism, male clinicians were significantly more likely to diagnose a male patient as “other” (e.g., social anxiety and depression), compared to all other clinician/patient gender combinations, and this process appeared to be influenced by clinicians’ gender rather than patient gender which was further indicated by the follow-up Mann–Whitney analyses. This gender difference in clinicians is particularly interesting, especially considering that the provision of differential rates of diagnosis has traditionally been understood to be the result of clinicians assigning different diagnoses based on patient’s gender. Indeed, there have only been isolated findings of clinician gender affecting diagnosis ( Crosby and Sprock, 2004 ).

Nevertheless, the clinician gender difference found in this study can be interpreted in numerous ways. These findings may indicate the potential of gender stereotyping on part of the clinician, given the fact that male clinicians were more likely to apply sets of symptoms to male patients, whereas female patients were diagnosed differently despite exhibiting identical symptomatology. It can therefore be conjectured that male clinicians may perceive the same symptoms differently depending on the patient’s gender and the concomitant gender weighting of the symptoms. Narcissistic vulnerability symptoms overlap with many “typically feminine” disorders (e.g., BPD and DPD), and thus might account for clinicians’ diagnostic bias toward categorization of female but not male patients. This would resonate with Flanagan and Blashfield’s (2003) study, showing that when participants are taught gender associations with the personality disorder categories, they are more likely to rate the personality disorder cases in accordance with those associations (e.g., BPD associated with females and ASPD associated with males).

Moreover, despite the overwhelming evidence that grandiose narcissism (NPD DSM) appears to be diagnosed more often in males than in females, the results of this study showed clinicians were attributing the diagnosis in a gender-neutral fashion. This finding is less consistent with theoretical speculation that clinicians are gender biased in application of diagnostic sets in relation to male patients (e.g., Anderson et al., 2001 ). It could be argued that the differential prevalence rates within males and females diagnosed with NPD in the DSM-5 may simply be an artifact of actual sex differences, where males are more likely to present features of grandiose narcissism compared to females ( Euler et al., 2018 ). These findings are important considering the criticism that may be leveled at the current aims of this study—investigating gender bias in a condition that is inherently gender-biased. Instead, what these findings show is that, at least for clinicians, their understanding of NPD is not necessarily that it is exclusively a male pathology. However, it also needs to be acknowledged that the discrepancy between the findings here and previous research may be partly due to differences in diagnostic criteria and assessment instruments.

Results further showed that clinicians with a psychodynamic orientation, but not CBT, were significantly more likely to diagnose vulnerable narcissism as NPD. It is not surprising that a psychodynamic approach would recognize vulnerable features of narcissism in its theoretical formulations. Psychodynamic approaches tend to emphasize personality development, relational and intrapsychic dynamics which are guided by the work of, among others, Kernberg (1975) and Kohut (1977) . CBT clinicians, on the other hand, are more rigid in the sense that they tend to focus entirely, if not exclusively, on immediate symptoms and cognitions rather than on the concept of personality ( Hofmann and Hayes, 2019 ). In terms of clinical implications, these findings provide more credence to other diagnostic manuals that contain a more comprehensive diagnostic definition of NPD, spanning grandiose and vulnerable features (e.g., PDM-2; Lingiardi and McWilliams, 2017 ).

Nevertheless, the finding that a clinician’s theoretical orientation affects their diagnostic judgment has an impact on how patients are assessed, the treatment plans constructed, and possibly the effectiveness of such interventions. Future research should replicate and explore these patterns using more established manuals such as the PDM-2 and the ICD-11. The results of this study also showed that the more experience a clinician had, the more likely they were to attribute vulnerable narcissism as being NPD. It is stressed here that the DSM-5 diagnostic procedure as it currently stands is questionable in its suitability for purpose, as clinicians are only able to diagnose vulnerable narcissism as NPD once they have gained experience in the differences between NPD as captured in the DSM nomenclature and the psychiatric phenomenon that they observe of narcissism in practice.

Limitations and future directions

Given the vignette-based design of this study, it is difficult to determine the extent to which current results can be generalized to actual clinician-patient interactions and diagnostic interviews. One clinician even declined to partake in this study on the grounds that they considered it unethical to provide a personality diagnosis based on a short description of a patient vignette. Therefore, it is arguable that a limitation of this study is that the use of clinical case vignettes, and not actual patients, may have influenced the external validity of the study. In addition, although the sample size ( n = 108) is comparable with prior research in this field, the relatively modest sample size between the groups (29 males), may have been underpowered to detect differences. Nevertheless, it was possible to identify a number of significant differences were obtained despite these limitations.

In terms of suggestions for future directions, it would be of interest to explore whether gender differences occur or are diminished according to which particular symptoms are displayed in vignettes. Such data may allow for the delineation of specific symptoms which impact on the presentation of narcissism in males and females, and thus may require gender-sensitive interventions that address such indicators. Future research should also explore gender differences in patients with narcissistic pathology to evaluate whether expressions of narcissism shift depending on the severity of dysfunction ( Kealy et al., 2016 ).

Future research should also consider exploring gender bias in narcissistic pathology using dimensional ratings derived from a Five Factor Model of personality (FFM; Widiger and Costa, 2002 ), such as the ICD-11, Personality Inventory for DSM-5 (PID-5; Krueger et al., 2014 ) or the Five-Factor Narcissism Inventory (FFNI; Miller et al., 2013 ). Moreover, in line with growing evidence that individuals fluctuate between grandiose and vulnerable states (e.g., Pincus et al., 2009 ; Edershile et al., 2019 ; Edershile and Wright, 2021 ), future research should explore clinician perception of narcissistic pathology in women across different state measures (e.g., EMA, Ecological Momentary Assessment) and the extent to which these perceptions influence diagnostic conceptualization. Such foci would complement the findings of the current study and expand theoretical knowledge regarding gender disparities in narcissistic presentations. Finally, the current study could be replicated to explore whether a clinician’s own gender role attributes gender bias when responding to a patient’s symptoms. This is particularly noteworthy considering previous research showing bias in the application of personality diagnosis, with symptoms that were inconsistent with a clinician’s gender role being viewed as more pathological in contrast to symptoms that were consistent with clinician’s gender role viewed as being less pathological ( Crosby and Sprock, 2004 ).

Overall, the results of this study contribute novel knowledge of how clinicians perceive pathological narcissism in females, through identifying characteristics on the part of the clinician that influence likelihood of diagnosis in cases with vulnerable narcissism symptomatology. These findings ultimately pose challenges to the theoretical and clinical utility of NPD captured in the nosological system in relation to gender, the differential prevalence rates among males and females, and the overlap of vulnerable narcissism with other personality disorders. The clinical implications of these findings accentuate the growing recognition of the limitations in the assessments of personality disorders as discrete clinical conditions (see Hopwood et al., 2018 ).

Data availability statement

Ethics statement.

The studies involving human participants were reviewed and approved by the Edinburgh Napier University Research Ethics Committee. The participants provided their written informed consent to participate in this study.

Author contributions

AG was responsible for the conception and design of the study, data collection, performed the statistical analyses, and wrote the first draft of the manuscript. RM contributed to the design, statistical analyses, and reviewed and edited the manuscript. KC contributed to the design and reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.

Acknowledgments

We would like to thank Dr. Craig Malkin and Dr. Jon Patrick for their advice regarding the design of this study, and Dr. David Kealy for kindly sharing the clinical case vignettes. We would also like to thank Dr. Claire Hart and Dr. Gayle Brewer for their feedback on earlier versions of this manuscript.

1 Although the current study focuses on gender differences, we have used the terms “sex bias” and “gender bias” in this paper to reflect the language adopted by the original authors, and although these constructs are similar, we acknowledge that they are distinct and not necessarily interchangeable.

2 Due to the journal’s word restrictions, subsequent analyses on NPD are included in Supplementary material .

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2023.1090746/full#supplementary-material

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