Interpersonal problems associated with narcissism among psychiatric outpatients: A replication study
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Archives of Psychiatry and Psychotherapy, 2018; 2: 26–33
DOI: 10.12740/APP/90328
Interpersonal problems associated with narcissism
among psychiatric outpatients: A replication study
Joanna Cheek, David Kealy, Anthony S. Joyce, John S. Ogrodniczuk
Summary
Background: Narcissistic personality disorder is the subject of increasing attention in the literature. Howev-
er, there remains a relative absence of empirical work that has examined narcissism in clinical samples, es-
pecially efforts to replicate previous findings. Findings from a previous large-scale study [1] suggest that nar-
cissism is associated with considerable interpersonal impairment.
Aims: The objective of the present study was to replicate the findings of Ogrodniczuk and colleagues in an in-
dependent sample of psychiatric outpatients.
Method: Consecutively admitted patients (N=53) to a day treatment program completed measures of narcis-
sism, interpersonal problems, and general psychiatric distress. The association between narcissism and in-
terpersonal impairment at baseline and post-therapy was examined. The relation of narcissism to treatment
discharge status was also investigated. Partial correlation analyses were used.
Results: At baseline, higher levels of narcissism were significantly associated with more interpersonal impair-
ment, particularly characterized by domineering, vindictive, and overly nurturing behaviour. Baseline narcis-
sism was also significantly related to interpersonal impairment at post-therapy. Change in interpersonal diffi-
culties following treatment was not significantly associated with baseline narcissism. Treatment discharge sta-
tus also was unrelated to narcissism.
Discussion: Implications for further treatment and clinical considerations are discussed.
Conclusions: The findings largely replicate those of Ogrodniczuk and colleagues’ earlier study, underscoring
prominent interpersonal impairment associated with narcissism and supporting the notion of narcissistic per-
sonality disorder as a valid clinical construct.
Narcissism, Interpersonal Functioning, Psychiatric Outpatients
Narcissistic personality disorder is described as tients with pathological levels of narcissism be-
a pervasive pattern of grandiosity, need for ad- lieve they are special and unique, have a sense
miration, and lack of empathy [2]. Being preoc- of entitlement, are exploitive and arrogant. They
cupied with fantasies of unlimited success, pa- exaggerate minor achievements, expect praise
and recognition without doing anything to earn
it, and feel entitled to express their opinion with-
Joanna Cheek,1 David Kealy,1 Anthony S. Joyce2, John S.
Ogrodniczuk1: 1 Department of Psychiatry, University of British Co-
out being burdened by listening to those of oth-
lumbia, Vancouver, Canada; 2 Department of Psychiatry, University ers. Perhaps not surprisingly, narcissistic pa-
of Alberta, Edmonton, Canada thology tends to be accompanied by a multi-
Declaration of interest: The authors declare no conflicts of interest.Interpersonal problems associated with narcissism among psychiatric outpatients: A replication study 27 tude of interpersonal problems. Presenting as ality psychology field with non-clinical sam- haughty, arrogant, entitled, and dismissive can ples. While these non-clinical studies provide leave others feeling befuddled, angry, insulted, a wealth of knowledge on trait narcissism, their and helpless. Difficulties interacting with oth- relevance for validating the NPD construct is ers place narcissistic patients at risk for signifi- limited [11,12]. Nevertheless, studies of non-clin- cant disruptions in their career, social, and fam- ical samples have linked narcissism to the inter- ily-life trajectories. personal difficulties of hostility [13], a domineer- The scientific literature on NPD includes dis- ing/vindictive style ([14,16], coldness, defensive- cussion of the scarcity of evidence supporting ness, and emotionally detached attachment be- its validity [3,4]. Links et al. [5] conclude, “Most haviours [17] and antagonism [18,19]. of the literature regarding patients suffering Fewer studies have investigated interperson- with narcissistic personality disorder is based al functioning in clinical samples of NPD [11]. on clinical experience and theoretical formula- Among such studies, that of Ogrodniczuk et al. tions, rather than empirical evidence” (p. 303). [1] is the largest to date to examine the associ- At the time of the DSM-5 working group dis- ation between narcissistic pathology and inter- cussions to consider changes to the personali- personal functioning. High levels of narcissis- ty disorder construct and diagnosis, only 4% of tic features were significantly associated with the 15,000 scientific articles on DSM-IV person- greater levels of distress and interpersonal prob- ality disorders focused on NPD [4]. This is in lems, specifically with domineering, vindictive, contrast to escalating prevalence rates for NPD, and intrusive behaviour. Even when controlling with a recent epidemiological study [6] finding for other Cluster B personality disorders (his- a 6.2% lifetime prevalence in the general popu- trionic, antisocial and borderline), narcissism lation and an even higher prevalence of 9.4% in uniquely predicted interpersonal problems, es- younger cohorts (20-29 year olds). pecially in the domineering and vindictive di- Some studies have shown NPD to suffer from mensions. Domineering and vindictive behav- low discriminant validity, sharing common iour were found to decline as a function of treat- traits with other personality disorders and thus ment, whereas intrusiveness did not. In terms contributing to high rates of comorbidity within of the utility of the NPD construct, narcissism the personality disorder class [4,7,8], though this was strongly associated with failure to complete is a problem that is hardly specific to NPD alone. treatment, with the high narcissism group expe- Without research clearly supporting the DSM-IV riencing a 63% dropout rate, nearly twice that of operationalization of NPD (or a valid alterna- the low and moderate narcissism groups. tive), the DSM-5 working group’s proposal was Replication of research findings—obtaining to remove NPD from the DSM-5 [9]. However, the same findings with other samples for the hy- a major shift in classification to include dimen- pothesis tested in the original study—is neces- sional common traits would likely disrupt conti- sary for valid conclusions [20]. Recent research nuity with the DSM-IV to such an extent that our has shed light on the problem of limited replica- previous knowledge of NPD may become irrele- bility in psychological research: only 36-47% of vant [7]. Significantly, NPD was reinstated in the original studies are successfully replicated [21]. DSM-5 after strong disapproval from the wider These concerns are echoed in clinical research, community arguing that the evidence—regard- with many studies finding poor replicability less of its limited scope—and wealth of clinical [22,23]. The present study was developed to add experience suggest significant utility to the spe- confidence to the findings obtained by Ogrod- cific diagnosis of NPD. niczuk et al.’s [1] by attempting to replicate find- As interpersonal functioning is central to the ings regarding narcissistic pathology and inter- proposed DSM-5 criteria for NPD [10], empir- personal problems among patients with person- ical knowledge regarding the relationship be- ality dysfunction. tween NPD and interpersonal functioning could The objectives of the current study are simi- help to support the clinical utility of the NPD lar to those of the original study by Ogrodni construct. The vast majority of studies of nar- czuk et al. [1]: (1) To assess the association be- cissism have occurred within the social-person- tween narcissism and interpersonal problems, Archives of Psychiatry and Psychotherapy, 2018; 2: 26–33
28 Joanna Cheek et al.
both concurrently and longitudinally; (2) To as- PI-IV; 24], the Inventory of Interpersonal Prob-
sess the unique predictive power of narcissism lems-64 [IIP-64; 25], and the Outcome Ques-
in predicting interpersonal problems, when con- tionnaire-45 [OQ-45; 26]. The WISPI-IV was
trolling for the other Cluster B personality dis- completed at baseline only. The IIP-64 and OQ-
orders (i.e., Histrionic, Antisocial, Borderline); 45 were completed at baseline and at the end of
and (3) To assess whether narcissism is associ- treatment. Baseline Axis I and Axis II diagnoses
ated with treatment outcomes, such as failure to were assigned by the DTP therapist who con-
complete treatment and change in interperson- ducted the initial intake assessment according
al impairment. to the DSM-IV-TR [2].
Narcissism was assessed with the WISPI-IV
[24], a 214-item self-report questionnaire organ-
METHOD ized into 11 scales, with each scale correspond-
ing to one of the DSM-IV personality disorders.
Patients and Recruitment The WISPI-IV items and scales were derived
from the DSM personality disorder symptom
Fifty-three consecutively admitted patients to
criteria. However, they are different from oth-
the Day Treatment Program (DTP) of the Uni-
er self-report measures of personality disorder
versity of Alberta Hospital in Edmonton, Cana-
(e.g., SCID-II) because they have been translat-
da served as participants in this study. The DTP
ed and reformulated according to an interper-
is known to community referral sources as an
sonal theory of personality [27]. Validation stud-
outpatient service that treats patients with per-
ies demonstrate excellent internal consistency
sonality disorders or maladaptive personali-
and test-retest reliability [24] and good conver-
ty disorder traits. The DTP offers an ongoing,
gent and discriminant validity with the SCID-II
structured therapeutic milieu characterized by
[28,29]. Each item on the WISPI-IV is rated on
an emphasis on psychodynamic group psycho-
a 10-point scale (1 = “Never or not at all true of
therapy. Patients attend the program daily for
you”; 10 = “Always or extremely true of you”)
seven hours Monday through Thursday, and
and patients are asked to rate their usual selves
a half-day on Friday. Patients participate for
a time-limited period of 18 weeks. One to two during the past five years or more. Summary
patients are admitted and a corresponding num- scores for each scale (mean rating of the items
ber complete the program in a given week. No for each scale) were computed.
individual therapy is offered. The primary inclu- Interpersonal problems were assessed with
sion criteria for the program included the pres- the IIP-64 [25]. The IIP-64 is a self-report instru-
ence of a DSM-IV personality disorder or signif- ment designed to assess problems in interper-
icant personality dysfunction that does not ful- sonal interactions that either are reflected by
ly meet criteria for any particular DSM-IV Axis difficulties in executing particular behaviours
II disorder, and a minimum age of 18. Exclusion (It is hard for me to …), or difficulties in exercis-
criteria included active psychosis, organic men- ing restraint (I do ... too much). The instrument
tal disorder, acute suicidality, active substance is based upon interpersonal theories of behav-
abuse in need of primary attention, and involve- iour [30-32]. The scale consists of 64 items (8 sub-
ment with another mental health agency. Ethics scales of 8 items each) that are rated on a 5-point
approval for the study was obtained from the lo- scale. The subscales can be modelled geometri-
cal hospital and university ethics boards. After cally as a circumplex model. Each subscale rep-
complete description of the study to the subjects, resents an octant within this model. The 8 sub-
written informed consent was obtained. scales reflect interpersonal problems character-
ized by the following adjectives: Domineering,
vindictive, cold, socially avoidant, non-asser-
Assessment Measures tive, exploitable, overly nurturant, and intrusive.
In addition to the subscales, the IIP-64 provides
Each patient completed three self-report meas- a total score, reflecting overall distress associ-
ures for the purpose of this study. These includ- ated with interpersonal problems. For the pre-
ed the Wisconsin Personality Inventory-IV [WIS- sent study, the subscale scores were used to de-
Archives of Psychiatry and Psychotherapy, 2018; 2: 26–33Interpersonal problems associated with narcissism among psychiatric outpatients: A replication study 29
scribe interpersonal behaviours associated with three percent (N = 49) had received psychiatric
narcissism, while the total score was used to re- treatment in the past, and 30% (N =16) had been
flect overall interpersonal distress. The IIP-64 is previously hospitalized for psychiatric difficul-
a widely used instrument and has strong psy- ties. Seventy percent (N=37) of the patients were
chometric properties [33]. not working at the time of admission, with 9%
General psychiatric distress was assessed (N=5) working part-time and 21% (N=11) work-
with the symptom distress subscale of the OQ- ing full-time. The most prevalent DSM-IV Axis
45 [OQ-45; 26], a 45-item self-report meas- II diagnoses were Avoidant (35.8%), Borderline
ure. The items address common symptoms (22.6%), and Obsessive-Compulsive (18.9%),
and problems (mostly depressive and anxiety- while 7.5% of patients met full criteria for Nar-
based) that occur across the most frequently oc- cissistic Personality Disorder. The most preva-
curring psychiatric disorders. Each item is rated lent DSM-IV Axis I diagnoses were Obsessive
using a 5-point Likert scale, with a range of 0 to Compulsive Disorder (56.6%), Agoraphobia
4. The OQ-45 is frequently used and possesses (41.5%), Social Phobia (34%), and Post Traumat-
good psychometric properties [34]. ic Stress Disorder (32.1%).
Statistical Analyses Potential confounding variables
Partial correlation, controlling for confounding There were no significant associations between
variables, was used to examine the association narcissism and either age (r=0.08, p=0.56) or cur-
between narcissism and interpersonal problems. rent symptom distress (r=0.10, p=0.50). Similarly,
Sex, age, and baseline symptom distress were there was no significant association between nar-
examined as potentially confounding variables cissism and sex (t=1.22, p=0.23). Symptom dis-
(using t-test and bivariate correlation) and in- tress was, however, significantly correlated with
cluded in the partial correlation analyses as co-
the total score from the IIP (r=0.43, p30 Joanna Cheek et al. predict interpersonal problems over and above gram. As in the original study, after controlling other personality disorders that are related to for the effects of the other Cluster B personal- narcissism. We found that, after controlling for ity disorders, the present study found narcis- the effects of these other variables, narcissism sism to be significantly associated with the dom- remained significantly related to overall inter- ineering and vindictive interpersonal domains personal distress (r=0.40, p < 0.009), as well as at baseline, suggesting that these interpersonal the domineering (r=0.35, p < 0.022), vindictive styles may specifically discriminate narcissism (r=0.34, p < 0.024) and overly nurturing (r=0.38, from other personality disorders. These find- p
Interpersonal problems associated with narcissism among psychiatric outpatients: A replication study 31 [therapeutic discharge (completed treatment), study the outcomes for the participants who left administrative discharge (patient asked to leave treatment prematurely. Third, our sample size program), self discharge (patient-initiated pre- was relatively small, limiting the generalizability mature termination)] but not number of weeks of our findings. Fourth, our sample was drawn in the program. from a day treatment program that serves con- Our findings regarding the longitudinal asso- siderably impaired and symptomatic patients. ciation between baseline narcissism and inter- The extent to which our findings generalize to personal problems at the end of treatment sug- the broader outpatient population is unclear. Fi- gest that problematic interpersonal interactions nally, as the WISPI-IV was designed to be con- is a persistent problem in NPD. Interestingly, sistent with the DSM-IV, we assessed only the narcissism was more highly correlated with di- grandiose subtype of narcissism, characterized mensions of the IIP at post-treatment than at by grandiosity, aggression, and dominance [44]. pre-treatment. Though an explanation for this The field is moving toward accepting a vulner- finding is not immediately clear, it may be an ar- able subtype of narcissism, involving a more in- tefact of the treatment experience whereby high- ternalizing picture of shame, negative affect and ly narcissistic patients become more aware of the avoidance, which is not captured in the DSM- breadth of their interpersonal dysfunction after IV/5 construct of NPD [42,44,45]. The focus on 18 weeks of intensive, group-based treatment. the observable manifestations of narcissism de- Such a finding deserves further exploration in scribed in the DSM-IV/5 may improve discrimi- future studies. nant validity, but limit construct validity as the Similar to Ogrodniczuk et al.’s study, signif- scope of the disorder is narrowed. icant reductions were observed in all interper- Notwithstanding these limitations, the find- sonal dimensions. The magnitude of improve- ings of the present study support Ogrodniczuk ment, however, was not associated with narcis- et al.’s conclusions of prominent distress caused sism in either study. These findings were also by interpersonal problems associated with nar- echoed in Ellison et al.’s [42] study showing that cissism in clinical populations, particularly with- pathological narcissism did not significantly in- in the domineering, vindictiveness, and intru- terfere with symptom change in psychotherapy. sive domains. Our results provide further sup- As discussed in Ogrodniczuk et al.’s original pa- port for the validity of narcissism as a patholog- per, these findings may support the conclusions ical personality style associated with impaired that treatment specifically designed to treat per- functioning. While narcissistic pathology tends sonality disorders can be successful in modify- to make treatment more difficult, both Ogrod- ing the problematic interpersonal behaviours of niczuk et al.’s and our study show that people narcissism [43]. While narcissistic patients have with narcissism can change with the appropriate significant interpersonal impairments that may treatment. By more clearly delineating the spe- make therapy difficult, these findings suggest cific impairments associated with narcissism, we that they can achieve therapeutic change with hope future research may advance treatments to appropriately focused treatments. target these impairments. The findings of the present study should be considered in the context of various limiting REFERENCES factors. First, the self-report nature of our meas- ures may not fully reflect narcissistic dysfunc- 1. Ogrodniczuk JS, Piper WE, Joyce AS, Steinberg PI, Dug- tion, since narcissistic patients may employ so- gal S. Interpersonal problems associated with narcissism cially desirable responses to present themselves among psychiatric outpatients. J Psychiatr Research. 2009; favourably. However, as suggested in the orig- 43:837-842. inal study by Ogrodniczuk et al. [1], the WISPI- 2. American Psychiatric Association. Diagnostic and statistical IV is considered sufficiently capable of capturing manual of mental disorders (4th ed., text rev.). Washington, variation in the severity of narcissistic features DC: American Psychiatric Press; 2000. among participants [28]. Second, our study did 3. Blashfield RK, Intoccia V. Growth of the literature on the not use a naturalistic follow-up procedure (i.e., topic of personality disorders. Am J Psychiatry. 2000; follow-up without treatment). Thus, we did not 157:472–473. Archives of Psychiatry and Psychotherapy, 2018; 2: 26–33
32 Joanna Cheek et al.
4. Morey LC, Stagner BH. Narcissistic pathology as core per- 18. Miller JD, Hoffman BJ, Gaughan ET, Gentile B, Ma-
sonality dysfunction: Comparing the DSM-IV and the DSM- ples J, Campbell WK. Grandiose and vulnerable narcis-
5 proposal for narcissistic personality disorder. J Clin Psy- sism: A nomological network analysis. J Personality. 2011;
chology. 2012; 68:908-921. 79:1013–1042.
5. Links PS, Gould B, Ratnayake R. Assessing suicidal youth 19. Samuel DB, Widiger TA. Convergence of narcissism meas-
with antisocial, borderline, or narcissistic personality disor- ures from the perspective of general personality functioning.
der. Can J Psychiatry. 2003; 48:301–310. Assessment. 2008; 15:364–374.
6. Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang 20. Asendorpf J, Conner M, De Fruyt F, De Houwer J, Denissen
B, Smith SM, Ruan WJ, Pulay AJ, Saha TD, Pickering RP, J, Fiedler K, Fiedler S, Funder DC, Kliegel R, Nosek BA, Pe-
Grant BF. Prevalence, correlates, disability, and comorbidi- rugini M, Roberts BW, Schmitt M, van Aken MAG, Weber H,
ty of DSM–IV narcissistic personality disorder: Results from Wicherts JM. Recommendations for increasing replicabili-
the Wave 2 National Epidemiologic Survey on Alcohol and ty in psycholgy. In: Kazdin A, editor. Methodological Issues
Related Conditions. J Clin Psychiatry. 2008; 69:1033–1045. and Strategies in Clinical Research. 4th ed. Washington, DC:
7. Livesley WJ. Tradition versus empiricism in the current DSM- American Psychological Association; 2016. p. 607–622.
5 proposal for revising the classification of personality disor- 21. Open Science Collaboration. Psychology. Estimating the re-
ders. Crim Beh Mental Health. 2012; 22:81–91. producibility of psychological science. Science. 2015; 349:
8. Morey LC. Personality pathology as pathological narcissism. aac4716.
In: Maj M, Akiskal HS, Mezzich JE, Okasha A, editors. World 22. Ioannidis JP. Contradicted and initially stronger effects in
psychiatric association series: Evidence and experience in highly cited clinical research. JAMA. 2005; 294: 218–228.
psychiatry. New York, NY: Wiley; 2005. P.328-331. 23. Tajika A, Ogawa Y, Takeshima N, Hayasaka Y, Furukawa TA.
9. Skodol AE, Clark LA, Bender DS, Krueger RF, Livesley WJ, Replication and contradiction of highly cited research pa-
Morey LC, Bell CC. Proposed changes in personality and pers in psychiatry: 10-year follow-up. Brit J Psychiatry. 2015;
personality disorder assessment and diagnosis for DSM-5. 207:357–362.
Part I: Description and rationale. Personal Disorders. 2011; 24. Smith TL, Klein MH, Benjamin LS. Validation of the Wiscon-
2: 4–22. sin Personality Disorders Inventory-IV with the SCID-II. J
10. American Psychiatric Association. Diagnostic and statistical Personal Disorders. 2003; 17:173-187.
manual of mental disorders (5th ed.). Washington, DC: Au- 25. Horowitz L, Rosenberg SE, Baer BA, Ureno G, Villasenor
thor; 2013. VS. Inventory of Interpersonal Problems: Psychometric prop-
11. Miller JD, Campbell WK, Pilkonis PA. Narcissistic personali- erties and clinical applications. J Consult Clin Psychology.
ty disorder: relations with distress and functional impairment. 1988; 56:885-892.
Comprehen Psychiatry. 2007; 48:170-177. 26. Lambert MJ, Hansen NB, Umphress V, Lunnen K, Okiishi J,
12. Wright AGC, Pincus AL, Thomas KM, Hopwood CJ, Markon Burlingame GM, Reisenger CW. Administration and Scoring
KE, Krueger RF. Conceptions of Narcissism and the DSM-5 Manual for the OQ-45.2. Stevenson, MD: American Profes-
Pathological Personality Traits. Assessment. 2013; 20:339– sional Credentialing Services LLC; 1996.
352. 27. Benjamin LS. Interpersonal Diagnosis and Treatment of Per-
13. Bushman BJ, Baumeister RF. Threatened egotism, narcis- sonality Disorders, 2nd ed. New York: Guilford Press; 1996.
sism, self-esteem, and direct and displaced aggression: 28. Barber JP, Morse JQ. Validation of the Wisconsin Personal-
Does self-love or self-hate lead to violence? J Personal Soc ity Disorders Inventory with the SCID-II and PDE. J Person-
Psychology. 1998; 75:219-229. al Disorders. 1994; 8:307–319.
14. Besser A, Priel B. Grandiose narcissism versus vulnerable 29. Klein MH, Benjamin LS, Rosenfeld R, Treece C, Husted J,
narcissism in threatening situations: Emotional reactions to Greist JH. The Wisconsin Personality Disorders Inventory:
achievement failure and interpersonal rejection. J Soc Clin Development, reliability, and validity. J Personal Disorders.
Psychology. 2010; 29:874–902. 1993; 7:285-303.
15. Besser A, Zeigler-Hill V. The influence of pathological narcis- 30. Kiesler DJ. Contemporary Interpersonal Theory and Re-
sism on emotional and motivational responses to negative search. New York: Wiley; 1996.
events: The roles of visibility and concern about humiliation. 31. Leary T. Interpersonal Diagnosis of Personality. New York:
J Res Personality. 2010; 44:520–534. Ronald Press; 1957.
16. Dickinson KA, Pincus AL. Interpersonal analysis of grandi- 32. Sullivan HS. The Interpersonal Theory of Psychiatry. New
ose and vulnerable narcissism. J Personal Disorders. 2003; York: Norton; 1953.
7:188-207. 33. Strupp HH, Horowitz LM, Lambert MJ. Measuring Patient
17. Smolewska K, Dion KL. Narcissism and adult attachment: Changes. Washington, DC: American Psychological Asso-
A multivariate approach. Self & Identity. 2005; 4:59-68. ciation; 1997.
Archives of Psychiatry and Psychotherapy, 2018; 2: 26–33Interpersonal problems associated with narcissism among psychiatric outpatients: A replication study 33
34. Ellsworth JR, Lambert MJ, Johnson J. A comparison of the 40. Kohut H. How Does Analysis Cure? Chicago: University of
Outcome Questionnaire-45 and Outcome Questionnaire-30 Chicago Press; 1984.
in classification and prediction of treatment outcome. Clin 41. Campbell MA, Waller G, Pistrang N. The impact of narcis-
Psychol Psychotherapy. 2006; 13:380–391. sism on drop-out from cognitive-behavioral therapy for eat-
35. Gunderson JG, Ronningstam E. Is narcissistic personality ing disorders: A pilot study. J Nerv Ment Disease. 2009;
disorders a valid diagnosis? In: Oldham JM, ed. Personality 197:278–28.
Disorders: New Perspectives on Diagnostic Validity. Wash- 42. Ellison WB, Levy KN, Cain NM, Ansell EB, Pincus AL. The
ington, DC: American Psychiatric Press 1991; p.107-119. Impact of Pathological Narcissism on Psychotherapy Utiliza-
36. Kernberg OF. Borderline personality organization. J Amer tion, Initial Symptom Severity, and Early-Treatment Symptom
Psychoanal Association. 1967; 15:641-685. Change: A Naturalistic Investigation. J Personal Assessment.
37. Millon T, Davis RD. Disorders of Personality: DSM-IV and Be- 2013; 95:291–300.
yond, 2nd ed. New York: Wiley; 1996. 43. Kealy D, Ogrodniczuk JS. Narcissistic interpersonal prob-
38. Holtforth MG, Pincus AL, Grawe K, Mauler B, and Castonguay lems in clinical practice. Harv Rev Psychiatry. 2001; 19:290-
LG. When What You Want is Not What You Get: Motivation- 301.
al Correlates of Interpersonal Problems in Clinical and Non- 44. Miller JD, Gentile B, Wilson L, Campbell WK. Grandiose and
clinical Samples. J Soc Clin Psychology. 2007; 26:1095-1119. vulnerable narcissism and the DSM-5 pathological person-
39. Campbell KW, Foster JD. The Narcissistic Self: Background, ality trait model. J Personal Assessment. 2013; 95:284-290.
an Extended Agency Model, and Ongoing Controversies. In: 45. Pincus AL, Ansell EB, Pimentel CA, Cain NM, Wright A, Levy
Sedikides C, Spencer S, editors. Frontiers in social psychology: KN. Initial construction and validation of the Pathological Nar-
The self. Philadelphia, PA: Psychology Press; 2007. p. 115-138. cissism Inventory. Psychol Assessment. 2009; 21:365–379.
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