- When psychology looks at narcissistic personality disorder (NPD), it may be missing an important piece of the puzzle.
- A recent review of diagnostic approaches to NPD points to weaknesses in detecting the vulnerable form of this disorder.
- By rethinking psychology's approach to NPD's vulnerable form, individuals needing help can be better served.
When you think about someone who’s a narcissist, it’s most likely you focus on the individual’s grandiosity, tendency toward manipulation of others, and excessive need for attention. Getting to the underlying cause, you might then go on to imagine that this individual may be operating out of an inner weakness that leads to a flurry of self-aggrandizing behaviors. Even though you may not feel any particular sympathy for this very irritating person, it’s possible you occasionally wonder what, in their past, they’re trying to shove away in order to feel superior.
This observation may lead you to consider that there is another piece to narcissism, at least from a theoretical standpoint. From this perspective, the disorder may show up as its “vulnerable” form, in which the individual puts on a false outer shell to hide inner feelings of weakness and inferiority. Poke a hole in that fragile exterior, and anxiety, distress, and despondency will come pouring out.
You might be familiar with the fact that the current diagnostic system in use in the U.S. and Canada, the Diagnostic and Statistical Manual Fifth Edition (DSM-5), uses categorical distinctions to divide people into diagnoses of personality disorders. Prior to its publication in 2013, many professionals believed that the categories would disappear and be replaced by diagnostic dimensions. When this didn’t happen, a compromise of sorts was reached, and the DSM-5 authors offered an “alternate” dimensional system based on continuous rating scales. If empirically supported, this system (known as the AMPD) might eventually become the basis for diagnosing personality disorders.
Narcissism in the AMPD
The journal Personality Disorders: Theory, Research, and Treatment recently published a series of review articles in which recognized experts in the field examined evidence supporting each of the personality disorders from the AMPD perspective. In this issue, University of Georgia’s Joshua Miller and colleagues took on the task of seeing how Narcissistic Personality Disorder (NPD) would stand up to the statistical test of its validity.
You may be familiar enough with the idea of NPD, but technically, it is diagnosed only when an individual meets the so-called “Criterion A” and “Criterion B” categories. For Criterion A, the individual must be impaired in 2 out of this set of 4 areas of functioning: self-esteem dependent on others, need for approval from others in setting goals, lack of empathy, and superficial involvement in relationships. To meet Criterion B, the individual must exhibit two pathological traits- grandiosity and attention seeking.
It is the fact that only two traits are required for diagnosing Criterion B that leads Miller et al. to question the appropriateness of the DSM-5 approach. Other personality disorders include a larger number of traits, with borderline personality disorder requiring seven. Fewer traits means that Criterion B’s validity for NPD would be compromised.
The situation becomes more complicated when the AMPD is added to the diagnostic mix. The AMPD makes it possible to separate out, potentially, vulnerable narcissism as a variant of NPD, a refinement not present in the two traits needed for Criterion B. This would mean that an individual with vulnerable narcissism might not be properly diagnosed.
Why Diagnosis Matters
All of this confusion not only threatens the validity of a diagnosis, but can make a real difference in the life of an individual seeking treatment. Imagine a person with the vulnerable form of NPD who is plagued by feelings of inferiority and unhappiness. As the U. Georgia authors note, “vulnerable narcissism is associated with pervasive negative affectivity, introversion, egocentrism, a distrustful and anxious attachment style, low self-esteem, and both internalizing and externalizing symptoms” (p. 407). This person could miss out on important therapeutic interventions.
The AMPD, in its current form, doesn’t help matters very much, according to research that Miller and his colleagues reviewed. The self-report measure based on this model, the Personality Inventory for DSM-5 (PID-5), includes 220 trait-based rating items intended to capture the entire range of personality disorders, but in the NPD domain, it is heavily weighted toward those two Criterion B traits. Vulnerable narcissism all but disappears and may even, according to the authors, show up as “largely analogous to trait neuroticism or a general factor of psychopathology” (p. 408). Again, vulnerable narcissism evades the diagnostic focus even in this more elaborate dimensional approach.
You might argue, after reading this analysis, that there is no such thing as vulnerable narcissism, so that people experiencing what looks like its symptoms do not, in fact, have NPD. However, Miller et al. believed that it was still necessary to exhaust the possibilities and see where vulnerability-specific traits may appear upon closer examination.
Vulnerability’s Unique Qualities
Now, turning to the potentially unique contributions of vulnerability to the NPD diagnostic picture, the U. Georgia research team conducted a rigorous empirical review of previously-published studies looking at both the PID-5 and other narcissism-specific measures. The authors also compared these profiles to what was called an “expert” prototype, meaning a clinical compilation of NPD-associated qualities.
Supporting the idea that the NPD diagnosis captures mainly the grandiose variant, most measures plus the expert review correlated with traits reflecting attention-seeking and grandiosity. Perhaps somewhat ironically, the authors describe this finding as showing that: “grandiosity and attention seeking consistently account for the lion’s share of variance” (p. 408). Additional relationships showed up between NPD and antagonism, supporting the view that people with NPD have a strong mean streak.
When it came to vulnerability, in keeping with Miller et al.’s suggestion that this form of narcissism extends across a range of maladaptive traits, there were unique correlations between the vulnerable narcissism scale scores and the traits of anxiousness, rigid perfectionism, separation insecurity, depressivity, anhedonia (lack of enjoyment of life), withdrawal, distractibility, and submissiveness. However, those high in vulnerable narcissism also received high scores on the overall NPD grandiosity traits of callousness, risk-taking, and the DSM-5 trait of attention-seeking.
In summing up their findings, the U. Georgia researchers concluded that without specifiers to indicate the presence of vulnerable narcissism, the NPD diagnosis may fail to capture individuals with this broad set of dysfunctional qualities.
How to Understand the Vulnerable Narcissist
Knowing that vulnerability may hide in the shadows when you’re dealing with someone showing some of the classic signs of grandiosity and attention-seeking could help you provide new insights into managing your relationships with such individuals. It would appear from the Miller et al. findings that grandiosity may not mask inner vulnerabilities in a person with NPD, but it could. In the words of the authors, these two components of narcissism (plus, potentially antagonism) “are important as they likely have different etiological risk factors, psychological correlates, and require different treatment approaches” (p. 410).
To sum up, your relationship with a vulnerable narcissist may require that you look for those additional qualities suggested in that broad range of dysfunctional traits even though the person’s outward behavior may put you off completely. Helping that person find the right treatment could allow both of you to explore ways to achieve stronger and more fulfilling pathways through life.
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Miller, J. D., Crowe, M. L., & Sharpe, B. M. (2022). NaN(4), 407–411. https://doi-org.silk.library.umass.edu/10.1037/per0000534.supp (Supplemental)