Personality Disorders: Theory, Research, and

Treatment
Modernity and Narcissistic Personality Disorder
Joel Paris
Online First Publication, July 16, 2012. doi: 10.1037/a0028580
CITATION
Paris, J. (2012, July 16). Modernity and Narcissistic Personality Disorder. Personality
Disorders: Theory, Research, and Treatment. Advance online publication. doi:
10.1037/a0028580
Modernity and Narcissistic Personality Disorder
Joel Paris
McGill University
Narcissistic personality disorder (NPD) is a trait-based disorder that can be understood
as a pathological amplication of narcissistic traits. While temperamental vulnerability
and psychological adversity are risk factors for NPD, sociocultural factors are also
important. This review hypothesizes that increases in narcissistic traits and cultural
narcissism could be associated with changes in the prevalence of NPD. These shifts
seem to be a relatively recent phenomenon, driven by social changes associated with
modernity. While the main treatment for NPD remains psychotherapy, that form of
treatment is itself a product of modernity and individualism. The hypothesis is pre-
sented that psychological treatment, unless modied to address the specic problems
associated with NPD, could run the risk of supporting narcissism.
Keywords: narcissistic personality disorders, narcissism, personality traits, personality disorders,
modernity, individualism
The recent near-death and resurrection of
NPD in Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) is a good time to
take stock of the history of this diagnosis (Levy,
Ellison, & Reynoso, 2011) and of the research
supporting it (Campbell & Miller, 2011). In
February 2010, the American Psychiatric Asso-
ciation (www.dsm-5.org) announced that ve of
the 10 DSMIV categories of PD would be
removed from the upcoming DSM-5, and that
NPD would be one of them. The rationale to
remove NPD was a perceived lack of empirical
support evidenced by a sparse literature.
This decision can also be understood in light
of the agenda of the work group for personality
disorders (Krueger, Clark, Markon, Derringer,
Skodol, & Livesley, 2011). Their view was that
categorical diagnosis of PDs is arbitrary, and
that empirical data support continuity between
traits and disorders. Moreover, DSM-5 favors
dimensionalization of all psychiatric diagnoses
(Kupfer & Regier, 2011). With these principles
in mind, the revision focuses on making an
overall diagnosis of PD, using dimensionalized
descriptions to account for variations in trait
proles, and retaining only a few categories.
This approach has merit, but it is arguable
that categorical diagnoses should be retained
when they are theoretically coherent and sup-
ported by a body of empirical data (Millon,
2011). In the case of NPD, although data are
indeed thin on the personality disorder, there
has been recent and extensive research on nar-
cissistic traits, that is, subclinical levels of NPD
that have been consistently shown to be contin-
uous with the disorder (Cain, Pincus, & Ansell,
2008). This literature has been well summarized
in the recently published Handbook of Narcis-
sism and Narcissistic Personality Disorders
(Campbell & Miller, 2011). If there is no sharp
distinction between trait patterns and diagnos-
able disorder associated with dysfunction, then
research on traits could be directly applicable to
understanding the personality disorder. In this
respect, NPD is better supported by research
than some categories (avoidant, compulsive)
that have been retained and that were never
under threat of removal from DSM-5.
The decision to drop NPD created dismay
among researchers (Miller & Campbell, 2010;
Miller, Widiger, & Campbell, 2010) and expert
clinicians (Pies, 2011; Ronningstam, 2011).
Even the New York Times (November 30, 2010)
weighed in, suggesting wryly that narcissists
dont like being ignored. Then, in June 2011,
the work group reversed its decision. This
change may have occurred because of feedback
Elsa Ronningstam read an earlier version of this paper
and made useful suggestions for revision.
Correspondence concerning this article should be addressed
to Joel Paris, Institute of Community and Family Psychiatry,
McGill University, 4333 cote ste. catherine, Montreal Quebec
H3T1HE4. E-mail: joel.paris@mcgill.ca
Personality Disorders: Theory, Research, and Treatment 2012 American Psychological Association
2012, Vol. , No. , 000000 1949-2715/12/$12.00 DOI: 10.1037/a0028580
1
from clinicians that NPD is a useful construct
that describes a characteristic group of patients
in practice.
To diagnose NPD in DSM-5, the common
features of all PDs (signicant impairments in
self and interpersonal functioning) must be
present, manifest in self-functioning (excessive
need for approval, grandiosity, entitlement), and
interpersonal functioning (poor empathy and
problematic intimacy). The associated trait do-
main for NPD is antagonism, associated with
grandiosity (feelings of entitlement, either overt
or covert, and self-centeredness, a belief that
one is better than others) as well as attention-
seeking (excessive seeking for admiration).
This denition is fully consistent with a con-
tinuous relationship between NPD and narcis-
sistic traits. While narcissistic traits can be
adaptive (Beck & Freeman, 2002), extreme or
pathological narcissism describes a dysfunc-
tional level that is essentially equivalent to a
diagnosis of NPD. High scores on measures of
trait narcissism are also closely related to the
features of the disorder (Miller, Gaughan,
Pryor, Kamen, & Campbell, 2009). Moreover,
the NPD construct is rooted in well-researched
trait domains of personality such as the Five
Factor Model (Miller & Campbell, 2010; Miller
& Maples, 2011; Miller, Dir, Gentile, Wilson,
Pryor, & Campbell, 2010). To measure the traits
underlying NPD more specically, the Narcis-
sistic Personality Inventory (NPI), a measure
that is particularly sensitive to grandiosity, has
been widely used (Raskin & Terry, 1988). An-
other instrument, the Pathological Narcissism
Inventory (PNI), also has a close relationship to
the clinical diagnosis of NPD (Pincus, Ansell,
Pimentel, Cain, Wright & Levy, 2009).
There has been controversy about the precise
meaning of the construct of narcissism (Pincus
& Lukowitsky, 2010). One reason is that NPD
can take either a grandiose or a covert-
vulnerable form (Miller, Hoffman, Campbell,
& Pilkonis, 2008; Cain, Pincus & Ansell, 2009).
This review follows the recommendations of
Cain et al. (2008) to dene pathological narcis-
sism in terms of both grandiosity and vulnera-
bility. There has also been controversy about
the validity of the NPI (Ackerman, Witt, Don-
nellan, Trzesniewski, Robins, & Kashy, 2011;
Rosenthal, Montoya, Ridings, Rieck, & Hooley,
2011), and Rosenthal and Hooley (2011) have
questioned whether it measures self-esteem. But
pathological narcissism differs from normal
self-esteem: it is based on feelings of entitle-
ment and in a failure to ground assessment of
the self in objective accomplishments (Ron-
ningstam, 2010).
It should be kept in mind that personality
disorders are complex amalgams of traits and
symptoms and are not based on single endophe-
notypes (Paris, 2011). PDs are also less stable
over time than previously thought. Longitudinal
studies have shown that symptoms are rela-
tively transient, so that many patients no longer
meet criteria when followed over several years,
but that the traits that underlie PDs tend to be
more stable (Skodol, Gunderson, Shea,
McGlashan, Morey, & Sanislow, 2005). Unfor-
tunately, this line of research has not examined
NPD, about which we have little or no prospec-
tive data.
PDs differ in the extent to which they are
characterized by egodystonic symptoms or ego-
syntonic traits. For example, suicidal behaviors
tend to be egodystonic, and borderline PD is
associated with a very wide range of symptoms
(Zanarini, Frankenburg, Dubo, Sickel, Trikha &
Levin, 1998). In contrast, traits such as viewing
oneself as superior to other people tend to be
egosyntonic. Thus NPD, even when associated
with dysfunction, is rooted in traits that patients
may consider normal (Ronningstam, 2010,
2011). If NPD is not associated with prominent
symptoms, this helps to explain why these pa-
tients, particularly those with predominantly
grandiose features, may not seek psychological
treatment (Pincus & Lukowitsky, 2010).
It has been claimed that all PDs lie on a
continuum with normal personality traits (Costa
& Widiger, 2001; Livesley, 2011). However
this conclusion, largely based on community
studies of personality, may not apply to all
clinical groups, because it fails to take into
account the distinction between egodystonic
and egosyntonic features. PDs such as border-
line personality have symptoms that may not be
seen in subclinical cases (Paris, 2007) and that
are difcult to describe by trait dimensions
alone. In contrast, when PDs are dened by
traits amplied to the point of dysfunction, one
would not expect to nd any clear separation
between disorder and dimensions. NPD is an
excellent example. Because its features are
highly egosyntonic, a dimensional model is
most appropriate, and the cut-off for diagnosis
2 PARIS
should be quantitative rather than qualitative.
This provides a rationale for applying research
on narcissistic traits, both in clinical and com-
munity populations, to understanding NPD
(Cain et al., 2008).
NPD Is Prevalent
Several recent studies have examined the prev-
alence of NPD in community and clinical popu-
lations. A national epidemiological survey of sub-
stance abuse (Stinson, Dawson, Goldstein, Chou,
Huang, & Smith, 2008) reported a surprisingly
high prevalence (6.2%) for NPD. However, the
cutoff between traits from disorders in PDs re-
quires clinical judgment, and ratings in this study
were made by research assistants rather than by
trained clinicians. A reanalysis of the same data
applying a different cut-off for diagnosis by Trull,
Jahng, Tomko, Wood, and Sher (2010) yielded a
much lower estimate, 0.7% for males and 1.2%
for females. A systematic review of several other
published studies (Dhawan, Kunik, Oldham &
Coverdale, 2010) found a mean community prev-
alence of 1%. Yet even this lower gure makes
NPD a highly prevalent disorder.
NPD may be more common in clinical pop-
ulations than in the community, and the largest
study reported a prevalence of 2% (Zimmer-
man, Rothschild & Chelminski, 2005). This
suggests that in spite of the egosyntonic nature
of NPD, patients (particularly those with a more
vulnerable prole) can be help-seeking. More-
over, research shows many patients with NPD
are distressed, lonely, and have poor social
functioning (Miller, Campbell, & Pilkonis,
2007). These outcomes could be a result of
unsuccessful attempts by these patients to get
others to meet their needs. NPD patients are
more likely to be divorced and/or become un-
employed, often leading to depressive symp-
toms (Ronningstam, 2011). And while narcis-
sism declines with age (Foster, Campbell &
Twenge, 2003), long-term interpersonal prob-
lems can have cumulative effects. Finally, if, as
Twenge (2011) has suggested, trait narcissism
is on the increase, the prevalence of diagnosable
NPD could also be increasing. This hypothesis
cannot, however, be tested by cross-sectional
data and needs to be examined in cohort studies.
Up to now, that research design has only been
applied to antisocial PD (Moran, 1999).
NPD Is Biopsychosocial
NPD, like other mental disorders, can best be
understood in a biopsychosocial model. Behav-
ioral genetic studies of NPD (Torgersen,
Lygren, Oien, Skre, Onstad, & Edvardsen,
2000), as well as of narcissistic traits (Vernon,
Villani, Vickers, & Harris, 2008), show that
both have a heritable component accounting for
about 40% of the total variance. This suggests
that individuals are not likely to develop NPD
without rst having a trait prole that makes
them vulnerable to this disorder. Yet behavioral
genetic ndings also leave a large scope for
environmental inuence. Studies consistently
show that the environmental component in per-
sonality and personality disorder is unshared,
that is, that siblings growing up in the same
family do not necessarily have similar traits
(Livesley, Jang, Jackson & Vernon, 1998).
Moreover, if narcissistic traits precede NPD,
these characteristics should be observable in
childhood. This has been shown to be the case
by several research groups (Thomaes, Stegge,
Bushman, Olthof & Denissen, 2008; Kerig &
Stellwagen, 2010; Tackett & Mackrell, 2011;
Hill & Roberts, 2011).
Some of the specic psychological risk factors
that amplify narcissistic traits to pathological lev-
els have been investigated, but this research is in
its early stages. The current literature suggests a
role for permissiveness for grandiose narcissism
and for cold overcontrol in vulnerable narcissism
(Horton, Bleau, & Drwecki, 2006; Horton, 2011).
The rst mechanism would be relevant to cultural
trends that support parental and social reinforce-
ment of grandiosity (Twenge & Campbell, 2009).
These pathways raise the possibility of cohort
effects on narcissism, mediated by sociocultural
forces.
Twenge and Campbell (2006, 2009) have ex-
amined this issue. In surveys of university stu-
dents, comparing results at different historical
periods (30 years ago vs. the present), contem-
porary subjects were more likely to have high
NPI scores. Their conclusion was that narcissis-
tic traits are increasing over time. Support for a
cohort effect has also come from a meta-
analysis of published studies, which found that
self-reported empathy among university stu-
dents to be decreasing over several decades
(Konrath et al., 2011).
3 MODERNITY AND NARCISSISTIC PERSONALITY DISORDER
These conclusions have stimulated some con-
troversy. The most obvious limitation is that the
ndings are based on self-reports of college-
educated youth. The generalizability of ndings
from students is always problematic, and obser-
vations in broader community samples are
needed. While some researchers have failed to
replicate these ndings (Trzesniewski, Donnel-
lan, & Robins, 2008a, 2008b; Donnellan,
Trzesniewski, & Robins, 2009), discrepancies
may reect the use of different samples: college
populations differ in the proportion of native-
born and immigrant populations, and immi-
grants could be less likely to show narcissistic
traits (Twenge, 2011). However, surveys of nar-
cissism need to be conducted in more broadly
based samples.
Twenge (2011) found some support for her
hypothesis that narcissistic traits are on the in-
crease using other methods. One of the more
interesting directions involved the study of
changes in cultural products. Thus, narcissistic
themes have been increasing in the linguistic
content of popular song lyrics, particularly after
2000 (DeWall, Pond, Campbell & Twenge,
2011). Obviously, these measures are indirect,
and more research in community populations is
needed. Narcissistic traits also need to be stud-
ied in populations at different socioeconomic
levels, and with different cultural backgrounds.
While Twenges hypothesis of increasing cul-
tural narcissism is intriguing, her use of the term
epidemic to describe narcissism in contempo-
rary society (Twenge & Campbell, 2009) is
overdrawn. At this point, the hypothesis of a
cohort effect requires further empirical support.
Even so, the idea that narcissism is increasing
is consistent with a number of observations by
social scientists and historians. If the hypothesis
is supported by further research, we would need
to know whether this change reects a recent
and dramatic change, or a gradual evolution
over a longer period. Twenge (2011) suggests a
specic mechanism for a cohort effect, propos-
ing that sociocultural changes in parenting prac-
tices inuence levels of narcissism. Thus the
mechanism behind an increase could depend on
permissiveness, overindulgence, and the pro-
motion of self-esteem independent of accom-
plishment. These problems would go beyond
the idiosyncracies of specic families and de-
rive from the culture at large.
There is also evidence that culture plays a
role in shaping modal proles of personality.
While broad trait dimensions are universal, one
can observe signicant cross-national and
cross-cultural differences (Eysenck, 1995;
Costa, Terracciano & McCrae, 2001). Unfortu-
nately, there has been no specic research as to
whether narcissism shows variability across
cultures. In line with likely differences between
immigrant and native-born populations in West-
ern countries, these traits may be more preva-
lent in modern than in traditional societies. Dur-
vasula, Lysonski, and Watson (2001) developed
a Vanity Scale, which they administered to
samples in the United States, New Zealand,
India, and China. They found that subjects in
India and China were less concerned about their
physical appearance, or their achievements,
than those living in the United States or New
Zealand. NPI scores are higher in the United
States than in Asia or the Middle East (Foster,
Campbell, & Twenge, 2003). Moreover, one
study found that people who live in these coun-
tries share common perceptions of differences
in national character that tend to support what
have sometimes been considered stereotypes
(Campbell, Miller & Buffardi, 2010). Yet as
globalization proceeds, these cross-cultural dif-
ferences could become attenuated with time.
Even so, if narcissistic traits exist in a sociocul-
tural context, their prevalence can be expected
to show changes that depend on social forces.
Modernity and Narcissism
It has long been hypothesized by social sci-
entists that the characteristics of modern society
promote a greater focus on the self, as opposed
to the collective (Markus & Kituyama, 1991).
Modernity has been the subject of intensive
study by sociologists over several decades (Gid-
dens, 1998). This term describes cultural
changes and shifts in values associated with
industrial and postindustrial society, associated
with a decline in tradition and social norms.
These trends have been identied by historians
during the 19th and early 20th centuries and
probably date back to the 18th century Enlight-
enment (Giddens, 1991).
Modernity could affect personality traits by
supporting what has been called expressive
individualism (Bellah, Madsen, Sullivan,
Swidler, & Tipton, 1985). As traditional social
4 PARIS
structures weaken, people focus less on con-
forming to external expectations, and more on
their inner feelings. These changes have been
accelerated by social and geographic mobility;
as traditional social structures weaken, roots in
family and community become more fragile.
Moreover, as the social fabric weakens, the
community provides less of a buffer against the
vicissitudes of family life (Millon, 1993). Thus,
as society modernizes, collective values become
less important, and individual needs become
more prominent, while basic human needs for
connection and meaning are less easily met than
in traditional societies (Markus & Kitayama,
1994).
The key aspect of modernity for psychologi-
cal theory is individualism. The historical roots
of individualism lie in the Enlightenment, but
the term was rst used in the early 19th century
(Tocqueville, 1835/2000), gradually becoming
a central value in contemporary society (Fi-
scher, 2000). While autonomy and freedom
yield many social and personal benets (Deci &
Ryan, 2002), individualism can carry a price.
When the ultimate standard is what is good for
oneself, rather than for family and/or commu-
nity, people assess their actions on the basis of
personal satisfaction, rather than by commit-
ment to larger ideals (Rieff, 1966). This raises
the question as to whether individualistic val-
ues, if held too strongly, shade into narcissism.
It needs to be emphasized that while moder-
nity has its challenges, it is associated with
numerous positive benets, from better physical
health and decreased violence (Pinker, 2011) to
increased well-being (Deci & Ryan, 2002). But
social change is a kind of selection pressure that
could have different effects on different people,
and may have unique effects on vulnerable in-
dividuals (Rutter & Smith, 1995). Thus resil-
ience to adverse life events is common but is
associated with personality characteristics that
include an optimistic attitude, an ability to as-
sess risks and consequences, and an ability to
regulate emotions (Westphal & Bonnano,
2007). These characteristics could make people
who have resilient traits better equipped to deal
with modernity and rapid social change. In con-
trast, individuals with problematic personality
traits are at greater risk for developing mental
disorders (Rutter & Smith, 1995). Thus moder-
nity could be more positive for individuals with
characteristics that help them to cope with
change but negative for those whose vulnera-
bility makes coping more difcult.
Patients with PDs have many problematic
traits and can be described in the Five-Factor
Model as having low agreeableness, low con-
scientiousness, and high neuroticism (Costa &
Widiger, 2001). These trait dimensions, also
associated with narcissism (Miller et al., 2010),
may interfere with adaptive responses to social
stressors. In NPD, the grandiose subtype may
also be vulnerable to adversity, because behind
a mask of arrogance, pathological narcissism
fails to address inner neediness (Ronningstam,
2010). This raises a question concerning the
extent to which NPD patients require social
structures and networks.
There is good evidence for a universal human
need for attachment, in both interpersonal and
social contexts (Baumeister & Leary, 1995).
This observation is also consistent with socio-
logical concepts, which since the time of
Durkheim (1897/1997), have linked psycholog-
ical distress to social alienation. The concept of
social capital (Putnam, 2000) describes the
healthy inuence of social networks on psycho-
logical functioning. But when social capital is
insufcient, people may turn to themselves for
afrmation. This can lead to a cycle in which
poor social supports reinforce narcissism.
Two caveats should be entered here. First,
these social pathways need not be specic to
NPD. Similar mechanisms have been invoked
to explain increases in the prevalence of other
personality disorders, including the antisocial
category (Rutter & Smith, 1995) and the bor-
derline category (Millon, 1993; Linehan, 1993;
Paris, 1996). Second, because NPD has a com-
munity prevalence of about 1%, the disorder
likely develops only in people with specic
temperamental proles.
Modernity and Cultural Narcissism
Because narcissism is associated with indi-
vidualist values, it should be most prevalent in
societies, and in subgroups within a society, that
have most strongly embraced that world-view.
Twenges (2011) review of empirical studies
argues for a cohort effect dating back to the
1980s. However, the cultural changes affecting
narcissistic traits probably go back much
further.
5 MODERNITY AND NARCISSISTIC PERSONALITY DISORDER
Narcissism is hardly a new historical phe-
nomenon. No purely collectivist traditional so-
ciety has ever been described; in every histori-
cal period, ambitious people have indulged in
self-display and sought fame and attention
(Baudry, 1986). What is unique about modern
societies is that they promote values that en-
courage narcissism in everyone, not just in an
elite (Lasch, 1979). Even if these trends have
accelerated in recent decades, most observers of
modernity (e.g., Giddens, 1991) have suggested
a turning point around the year 1900.
If the effects of modernity were gradual and
cumulative, they may not have been clearly
observed until they reached a tipping point.
Increased interest in narcissism among psycho-
therapists and social critics dates from the 1960s
and 1970s, and these observations could be re-
lated to the social changes that characterized
those decades (Marwick, 2000). Some of the
most important clinical theories about NPD,
including the work of Kohut (1970) and Kern-
berg (1976), as well as cultural theories of nar-
cissism (Lasch, 1979), also date from this era.
The historian Christopher Lasch introduced
the term cultural narcissism to describe
how excessively individualistic values affect
contemporary society. Lasch (1979) hypothe-
sized that modern society encourages individ-
uals to focus on self and to loosen ties to
community and that contemporary culture has
come to focus on fame, celebrity, and riches
(as opposed to duty, honor, and service).
Lasch suggested that social developments in
the course of the 20th century amplied nar-
cissistic traits, producing fragile self-con-
cepts, fear of commitments and lasting rela-
tionships, a dread of aging, and an excessive
admiration for celebrity.
Others, including popular observers
(Wolfe, 1976), have described similar trends.
A political philosopher, Amitzai Etzioni
(1993), saw modern society as atomizing the
individual and ignoring the universal human
need for social networks and connections.
Putnam (2000) saw modernity as reducing
social capital, making people turn to self
rather than to community. All these processes
describe an individualism that became ex-
treme, shading into narcissism, and leading to
social disconnection.
Narcissism and Psychotherapy
To understand the relation between narcis-
sism and psychotherapy, one needs to consider
the social role of psychological treatment
(Cushman, 1990). Talking therapy did not exist
before a little over a hundred years ago. That
was the same time as the acceleration of mo-
dernitywhich may not be a coincidence. The
rise of psychotherapy may have been in part an
attempt to deal with problems created by mo-
dernity, specically a less predictable social en-
vironment (Gellner, 1993).
Psychological treatment is a product of mod-
ern culture that has, in turn, had a profound
effect on contemporary values. Nearly 50 years
ago, the sociologist Phllip Rieff (1965) de-
scribed the development of a therapy culture
linked to radical individualism. Rieff noted that
social virtue had become less of an ideal in
modern culture and that the well-being of the
individual had become paramount over that of
society as a whole. He also observed that a
therapeutic orientation makes all truths con-
tingent and negotiable, undermining shared so-
cial values.
Other commentators have come to similar
conclusions. The psychologist Phillip Cushman
(1990) argued that modernity produces an
empty self, shorn of social meaning, and
strongly criticized psychotherapy for promoting
individualistic values over social connections.
The sociologist Frank Furedi (2004) elaborated
on these ideas in a book critiquing the develop-
ment of a therapeutic culture, in which self-
esteem becomes more important than social
commitment.
However, not all forms of psychotherapy
are the same. Most commentators on thera-
peutic culture have been critics of psycho-
analysis and psychodynamically oriented
therapies, which sometimes have a tendency
to encourage self-absorption (Gellner, 1993).
This could be less true for cognitive
behavioral therapy (Beck & Freeman, 2002)
and interpersonal therapy (Klerman & Weiss-
man, 1993), whose theories are oriented more
to the current social environment.
Nonetheless, the inner dynamic of all psycho-
therapies encourages patients to look inside the
self as a way of dealing with the outside world
(Furedi, 2004). For those who are overly con-
cerned with social demands, focus on the self
6 PARIS
might lead to a better balance. But for those
who are already grandiose and seeking of atten-
tion, talking therapy could become as much part
of the problem as a part of the solution. In this
way the classical elements of psychotherapy,
such as empathy and unconditional positive re-
gard (Rogers, 1951), can be double-edged.
Talking about oneself to a therapist who listens
carefully and offers support might even be con-
sidered a narcissists dream. In this way, some
forms of psychological treatment risk support-
ing the very traits that lead to dysfunction.
We do not know whether existing psycho-
therapies are effective for the treatment of NPD.
Several psychoanalysts have described ap-
proaches to the treatment of narcissism (Kohut,
1977; Kernberg, 1987; Ronningstam, 2010).
There are ve chapters on psychotherapy in the
Handbook of Narcissism and Narcissistic Per-
sonality Disorder (Campbell & Miller, 2011):
transference-focused psychotherapy, attach-
ment therapy, schema therapy, cognitive
behavioral therapy, and dialectical behavior
therapy. However, none of these methods has
ever been tested in clinical trials or shown to be
effective in samples of NPD patients. It is true
that treatment research for most PDs (with the
exception of the borderline category) is gen-
erally thin. But the reputation of patients with
NPD for being difcult may not be unwar-
ranted. There is some evidence that narcis-
sism interferes with psychotherapy (Ogrod-
niczuk, Piper, Joyce, Steinberg, & Duggal,
2009), but we need more empirical research
on this patient population, particularly con-
cerning the effect of narcissism on psycho-
therapy process and outcome.
The difculties associated with the psycho-
logical treatment of NPD could relate to the
general factors that research shows to impede
good outcome, such as a poor therapeutic alli-
ance and a tendency to externalize problems
(Orlinsky, Grawe & Parks, 1994). It is also
possible that psychotherapy, if it focuses exclu-
sively on the interests of individuals, carries an
intrinsic danger of reinforcing narcissism.
While no empirical studies have directly exam-
ined how therapists use the concept of self-
esteem, models that aim to increase regard for
the self, although more characteristic of popular
psychology than of evidence-based practice,
have had an inuence on the thinking of many
clinicians (Furedi, 2003; Satel & Sommers,
2006).
Treatment for patients with narcissistic traits
and NPD may require unique methods of psy-
chotherapy. Generic therapies developed for
common mental disorders are not consistently
useful for PDs, as has been shown to be the case
for borderline PD, which does not respond well
to standard approaches, often called treatment
as usual (Paris, 2010). Rather, BPD has been
found to remit with highly structured therapies
that are specically designed to deal with emo-
tion dysregulation and impulsivity, such as di-
alectical behavior therapy (Linehan, 1993).
Identication of traits that could be targeted
might also help to dene the elements that need
to be included in a specic therapy for NPD.
Thus treatment might need to offer ways to
challenge grandiosity effectively and to provide
tools to reduce vulnerability. Patients with NPD
may also need a better balance between indi-
vidual goals and social attachments. Develop-
ment of a model based on these principles could
then be followed by clinical trials to determine
efcacy.
Conclusions and Suggestions for Further
Research
This review offers a number of hypotheses,
each of which requires empirical conrmation.
The proposal that increasing cultural narcissism
is promoting the development of NPD and as-
sociated traits has some support from empirical
data, and from the social science literature, but
clearly requires much more research. Thus,
measures such as NPI scores need to be exam-
ined more systematically and move beyond
convenience samples to large community pop-
ulations, cross-cultural samples, and prospec-
tive research in population cohorts.
Second, the hypothesis that therapy runs the
risk of promoting narcissism has also not been
examined empirically. While narcissism proba-
bly makes psychotherapy more difcult, studies
are needed to examine the effects of therapy on
these traits, particularly in extended courses of
treatment, and in different modalities. The use
of standard measures of narcissism in psycho-
therapy research could shed light on these ques-
tions. Studies of how therapists of different per-
suasions view the problem of self-esteem might
also be illuminating. Finally, the suggestion for
7 MODERNITY AND NARCISSISTIC PERSONALITY DISORDER
a new method of psychotherapy specically de-
signed to modify narcissism could be the basis
of a long-term research project.
These lines of investigation would all take
time. While awaiting more denitive data, this
review aims to alert therapists and theoreticians
to place the problem of narcissism in a historical
and sociocultural perspective that goes beyond
individual life narratives. Psychotherapists can-
not change the culture and society in which we
live but can be aware of its contradictions and
avoid promoting values that have the potential
to support narcissistic traits.
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