Dorothy: Do you suppose we'll meet any wild animals? 
Tin Man: Mmm, we might. 
Scarecrow: Animals that eat straw? 
Tin Man: Some, but mostly lions, and tigers, and bears. 
Dorothy: Lions? 
Scarecrow: And tigers? 
Tin Man: And bears. 
Dorothy: Lions and tigers and bears, oh my!
The Wizard of Oz (1939)

If you follow the running list of the most popular blog posts on Psychology Today, you might very well get the impression that readers are obsessed with narcissists, particularly when it comes to love. Is this the state of modern-day romance? Are readers, like Dorothy in the Wizard of Oz, really consumed by the fear that the dating pool is filled with hidden dangers in the form of narcissists, sociopaths, and psychopaths (oh my!)? And does psychology, or pop psychology, with all of its advice about the myriad ways to detect whether our romantic partners are narcissists, really tell us anything meaningful about how to avoid such peril?

Time for a reality check.  

holbox/Shutterstock
Source: holbox/Shutterstock

In the spirit of my last post about whether schizophrenia exists, let’s examine whether there’s really such thing as a “narcissist,” and if so, what that might mean. The answer is complicated, because the term has different meanings in psychiatry, psychology, and lay speech.

Psychiatry, as a medical discipline that focuses on illness, avoids the terms narcissist or narcissism in favor of “narcissistic personality disorder” (NPD), a full-blown syndrome, or constellation of symptoms (see the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 criteria here) associated with clinically significant distress or impairment in functioning. Contrary to what we might expect given readers’ apparent vigilance for narcissists, the proportion of people with NPD in the general population actually appears to be quite low. While a lifetime prevalence of as much as 6.2 percent is sometimes cited,1 that figure is based on a national survey that was performed in 1982 by non-clinicians. Using the same survey data, but requiring that all reported symptoms of NPD be associated with distress or impairment, the revised incidence drops to 1 percent,2 a number consistent with other surveys reporting lifetime rates of NPD as low as 0 percent nationally, and in places like Iowa, to as high as 4.4 percent in New York.3,4

The apparent rarity of NPD was used, along with the finding that NPD has significant overlap with other psychiatric disorders, to argue that the personality disorder should be removed from DSM-5 altogether and that narcissism would be better conceptualized as a continuous trait or “dimension” instead of a categorical diagnosis.4,5 It was almost omitted, but after much debate, NPD was ultimately retained in DSM-5 as a personality disorder with specific diagnostic criteria, while also included in a separate chapter called “Alternative DSM-5 Model for Personality Disorders,” with a more dimensional conceptualization that features both aspects of normal personality and pathological personality traits.

The idea that narcissism might be better understood as a continuous trait comes directly from how the construct is modeled in psychology, where the focus is on the entire range of human brain functioning and behavior, not just pathology. According to this model, narcissism is a trait that can vary in intensity from not enough to healthy normality to pathological extremity, at which point it could be associated with NPD.

In psychological studies, the continuous trait of narcissism is most often measured and quantified using the Narcissistic Personality Inventory (NPI), a 40-item scale intended for use in nonclinical populations (i.e., “normal” people without psychiatric disorders). [Take the test for yourself here.]  An international survey reported that the average score on the NPI was 15.2, with the highest average score in the U.S. (15.3), followed by Europe (15.0), Canada (14.8), Asia (14.3), and the Middle East (13.9).6 Average NPI scores decline significantly with age (between 15 and 18 for a teenager, down to 11 to 13 for those over age 50). Other studies suggest above-average NPI scores of 17.8 among celebrities and 16.18 among students enrolled in Masters in Business Administration (MBA) programs.7

Considering that the total range of NPI scores can vary from zero to 40, these geographical and vocational variations are actually quite narrow, with only a few points separating them. Online sources claim that an NPI score above 17 or 20 might qualify you as either “flirting with narcissism” or being a “narcissist,” that violent prisoners have an average score of 23, and that a score above 30 “may be concerning." But there is no agreed-upon threshold at which one would be considered a narcissist, although published articles in both popular and research psychology are rife with examples in which being a narcissist is equated with merely having a comparatively high NPI score. For example, a 2014 study promoted in the lay press (see here on Huffington Post) and blogs (see here in Psychology Today) as suggesting that a single question—“To what extent do you agree with this statement: I am a narcissist”—can determine if someone is a “narcissist.” But in reality, what the study demonstrated was only that the answer to that single question—graded on a scale of one to seven—was positively correlated with one’s score on the NPI.8 That’s a far cry from saying anything about how a single question might be able to detect whether someone is a narcissist, which remains something of a meaningless term with no firm definition.

The NPI isn’t very helpful in distinguishing between normality and pathology because that isn’t its purpose. That’s what the DSM-5 criteria for NPD are for. In fact, a 2013 study found that patients with NPD did not score significantly higher on the NPI than healthy controls.9 This distinction illustrates how a psychiatric disorder can be thought of as lying at the extreme end of a continuous psychological trait, but also how such disorders can remain fundamentally different constructs. In psychiatry, NPD is more than just extreme or pathological narcissism; it’s a constellation of symptoms that includes narcissistic grandiosity along with envy, lack of empathy, and interpersonal exploitation that must be associated with distress or functional impairment.  

In much the same way, the continuous psychologic trait of narcissism is more multifaceted than mere “self-love,” especially as it’s measured by the NPI. At the healthy point of the continuum, narcissism has considerable overlap with related constructs such as self-confidence, extraversion, assertiveness, individualism, and a desire to lead. Psychologists Seth Rosenthal and Jill Hooley have noted that the NPI may in particular conflate narcissism with self-esteem based on positive responses to questions like “I am assertive,” “I like to be complimented,” “I see myself as a good leader,” and “I have good taste when it comes to beauty.”10 When narcissism overlaps with self-esteem, it’s easy to see why NPI scores are correlated with psychological health, optimism, happiness, and social status, and why people with higher scores tend to be seen by others as charming, popular, socially-confident, entertaining, attractive, and desirable mates.10,11

At the more pathological end of the continuum, narcissism as measured by the NPI is associated with self-absorption and vanity, arrogance and entitlement, lack of empathy, and a tendency toward interpersonal exploitation. Note that both the NPI and DSM-5's NPD more closely match the psychoanalytic “oblivious” or “grandiose” subtype of narcissism than the “hypervigilant” or “vulnerable” subtype associated with underlying feelings of shame and inadequacy. Still, self-esteem can be low in both variants, which seems to explain why people with NPD score lower on the NPI that we might expect.9

As a continuous trait, narcissism can get us into trouble in both excess and deficit. Having too much means an individual is likely to have significant problems with interpersonal relationships and suffer disappointment from unrealistic expectations about what they deserve from life. Too little can lead to serious difficulties with paralyzing self-doubt and low self-esteem. Both can result in anxiety, depression, self-destructive behavior, and suicidal thinking.

Mental health, it would seem, requires just the right amount of narcissism to make an individual confident, yet modest and humble; aspirational and successful, but not grandiose and exploitative; and able to love oneself, as well as others. Of course, in reality, few of us have just the right amount, which means that most of us struggle at times with maintaining a healthy balance.

In the final analysis, then, the term narcissist has little meaning in psychology and should probably be avoided in favor of sticking to talk about narcissism, where there’s considerable overlap between narcissism that’s dysfunctional and narcissism that’s adaptive. Normal people without a mental illness like NPD can have problematic narcissism that exists right alongside healthy narcissism (embodying the very premise of Psych Unseen).

In the world of relationships, the term narcissist is often used as a pejorative to describe someone who cares more about themselves than you. In truth, sometimes that’s healthy and sometimes it’s not, just as it sometimes means that you should move on and sometimes not. But trying to ferret out whether someone is a narcissist with some kind of quiz, whether it contains 40 questions, five, or only one, isn’t likely to be very helpful. Thinking about ending a relationship over narcissism? Don’t leave your mate because he or she tests positive on some kind of narcissism test—leave because of the behavior that has you worried that your mate is a narcissist in the first place.

On the other hand, if you think your relationship is worth saving, consider exploring your concerns with a therapist, either individually or as a couple. As with any diagnosis, labeling someone a narcissist and making a judgment based on that alone puts you at risk of losing an opportunity to learn more about your mate, yourself, and the way you love. 

wikipedia.org
Echo and Narcissus, John William Waterhouse (1903)
Source: wikipedia.org

In Parts 2 and 3 of this series we’ll take a closer look at why we’re attracted to narcissism, whether narcissism is increasing, and what we might be able to do about it. Stay tuned.

Joe Pierre and Psych Unseen can be followed on Facebook and Twitter.

To check out some of my fiction, click here to read the short story "Thermidor," published in Westwind earlier this year.

References

1. Stinson FS, Dawson DA, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV Narcissistic Personality Disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry 2008; 69:1033-1045.

2. Trull TJ, Jahng S, Tomko S, et al. Revised NESARC personality disorder diagnoses: Gender prevalence, and comorbidity with substance dependence disorders. Journal of Personality Disorders 2010; 24:412-426.

3. Lenzenweger MF, Lane MC, Loranger AW, et al. DSM-IV personality disorders in the National Comorbidity Survey—replication study. Biological Psychiatry 2007; 62:553-554.

4. Alarcon RD, Sarabia S. Debates on the narcissism continuum: Trait, domain, dimension, type, or disorder? The Journal of Nervous and Mental Disease 2012; 200:16-25.

5. Skodol AE, Bender DS, Morey LC. Narcissistic personality disorder in DSM-5. Personality Disorders: Theory, Research, and Treatment 2014; 5:422-427.

6. Foster JD, Campbell WK, Twenge JM. Individual differences in narcissism: Inflated self-views across the lifespan and around the world. Journal of Research in Personality 2003; 37:469-486.

7. Young MS, Pinsky D. Narcissism and celebrity. Journal of Research in Personality 2006; 40:463-471.

8. Konrath S, Meier BP, Bushman BJ. Development and validation of the single item narcissism scale (SINS). PLoS One 2014:9:e103469.

9. Vater A, Schröder-Abé M, Ritter K, et al. The Narcissistic Personality Inventory: a useful tool for assessing pathological narcissism? Evidence from patients with narcissistic personality disorder. Journal of Personality Assessment 2013; 95:301-308.

10. Rosenthal SA, Hooley JM. Narcissism assessment in social-personality research: Does the association between narcissism and psychological health result from a confound with self-esteem? Journal of Research in Personality 2010: 44:453-465.

11. Haslam C, Montrose VT. Should have known better: The impact of mating experience and the desire for marriage upon attraction to the narcissistic personality. Personality and Individual Differences 2015; 188-152.

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