narcissistic personality disorder research

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Narcissistic Personality Disorder in Clinical Health Psychology Practice: Case Studies of Comorbid Psychological Distress and Life-Limiting Illness

Narcissistic Personality Disorder (NPD) is characterized by a persistent pattern of grandiosity, fantasies of unlimited power or importance, and the need for admiration or special treatment. Individuals with NPD may experience significant psychological distress related to interpersonal conflict and functional impairment. Research suggests core features of the disorder are associated with poor prognosis in therapy, including slow progress to behavioral change, premature patient-initiated termination, and negative therapeutic alliance. The current manuscript will explore challenges of working with NPD within the context of life-limiting illness for two psychotherapy patients seen in a behavioral health clinic at a large academic health science center. The ways in which their personality disorder affected their illness-experience shared significant overlap characterized by resistance to psychotherapeutic change, inconsistent adherence to medical recommendations, and volatile relationships with providers. In this manuscript we will (1) explore the ways in which aspects of narcissistic personality disorder impacted the patients’ physical health, emotional well-being, and healthcare utilization; (2) describe psychotherapeutic methods that may be useful for optimizing psychosocial, behavioral, and physical well-being in individuals with comorbid NPD and life-limiting disease; and (3) review conceptualizations of NPD from the DSM-5 alternative model for assessing personality function via trait domains.

Introduction

Narcissistic Personality Disorder (NPD) is a psychological disorder characterized by a persistent pattern of grandiosity, fantasies of unlimited power or importance, and the need for admiration or special treatment. Core cognitive, affective, interpersonal, and behavioral features include impulsivity, volatility, attention-seeking, low self-esteem, and unstable interpersonal relationships 1 that result in a pervasive pattern of interpersonal difficulties, occupational problems, and significant psychosocial distress. Prevalence estimates of NPD range from 0 to 6.2% in community samples. 1 , 2 Of those individuals diagnosed with NPD, 50%–75% are male. 1 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) 1 classifies NPD as a Cluster B (“dramatic, emotional, and erratic”) personality disorder, a category that also includes Antisocial, Borderline, and Histrionic Personality Disorders.

Individuals with NPD experience significant physical and mental health comorbidities and social problems. Stinson and colleagues 2 found high 12-month prevalence rates of substance abuse (40.6%), mood (28.6%), and anxiety (40%) disorders among participants with a diagnosis of NPD. Core features of NPD that contribute to these mental health comorbidities include a higher frequency of experiencing shame, helplessness, self-directed anger, higher admiration of self, 3 and impulsivity. 4 NPD is a significant predictor of (a) making multiple suicide attempts, 5 (b) using lethal means to attempt suicide, 6 and (c) making suicide attempts in proximal relationship to being fired or experiencing domestic, financial, or health-related problems. 7 Regarding physical health outcomes, individuals with Cluster B personality disorders, including NPD, have demonstrated significantly higher mortality rates due to cardiovascular disease than those without personality disorders, even after controlling for relevant medical comorbidities. 8 , 9 NPD specifically is also associated with gastrointestinal conditions. 9 Not unexpectedly, NPD is strongly associated with high health care utilization across a variety of services. 8 , 10 Additionally, provider-patient relationships among individuals with NPD can be challenging due to interpersonal dysfunction marked by dramatic, emotional, and erratic thinking and/or behavior. From a behavioral standpoint, individuals with a Cluster B diagnosis are more likely to have (a) a criminal conviction (b) spent time in prison, (c) a history of interpersonal violence, 8 (d) caused pain or suffering to others, 8 and (e) evidenced overall impairment in social role functioning. 8

In terms of treatment, a limited body of research has investigated interventions for NPD using randomized controlled trials or other methodologically rigorous approaches. One systematic review published by Town and colleagues 11 found eight studies of “moderate” scientific rigor that demonstrated the positive effect of short-term psychodynamic psychotherapy (STPP). Several researchers have examined the impact of NPD on the psychotherapeutic relationship. 12 – 14 Tanzilli and colleagues 14 found that individuals treating patients with NPD were more likely to experience negative counter-transference feelings of disengagement as well as feeling criticized or mistreated. These authors highlight the core feature of narcissism—struggle to form intimate relationships—as a significant barrier to positive treatment outcome, due to the patient’s potential inability to form a safe and trusting relationship with the therapist. Other researchers have found that individuals with NPD have higher rates of self-terminating treatment. 15

One proposed treatment method for personality disorders was originally developed with the goal of providing brief psychological services to individuals with substance use disorders or medical nonadherence concerns. This approach revolves around the six-component “FRAMES” technique developed by Miller and Sanchez. 16 This method emphasizes the role of Feedback, Responsibility, Advice, Menu of Strategies, Empathy, and Self-Efficacy. This approach highlights guidelines for the patient and therapist in order to maximize the likelihood of behavioral change and therapeutic progress. 16 , 17 This strategy creates a structure in which the provider can limit the impact of transference and countertransference on the therapeutic process and focus on creating a team-oriented dynamic that is supported by limit-setting, strong boundaries, and minimization of “splitting” with other providers.

The following case studies describe the particular challenges of working with two adult patients with NPD in a clinical health psychology practice within a large academic health center in the Southeast United States.

Reasons for referral and presenting problems

Mr. X is a middle-aged, Caucasian male who was referred to the Psychology Clinic for assessment and treatment of depression. Medical record review revealed a complex medical and psychiatric history including several acute illnesses, multiple psychological conditions, a history of suicidality and involuntary psychiatric admission, as well as lack of adherence to behavioral recommendations regarding diet, exercise, and medication compliance. Approximately one year prior to his intake at our clinic, Mr. X experienced a life-threatening medical crisis. He noted that he hoped psychotherapy would support him in the goal of finding new meaning in his life.

At the time of his initial intake, Mr. X presented to the Psychology Clinic with an unusually long list of medical and mental health diagnoses. His primary concern during the initial phase of his treatment was depression. Although Mr. X’s unique personality was appreciated immediately, it was not until many months into treatment when behavioral patterns suggestive of a personality disorder emerged. After recognizing Mr. X’s pattern of volatile interpersonal encounters that was suggestive of either Borderline Personality Disorder or Narcissistic Personality Disorder (according to the guidelines explicated in the DSM-5), other symptoms indicative of NPD began emerging, particularly when standard treatment approaches were met with resistance and individual appointments often turned into crisis management sessions. The most salient features of NPD that interfered with Mr. X’s treatment progress were thoughts of grandiosity, need for admiration or special treatment, and fantasies of unlimited power or importance. For example, Mr. X regularly cancelled therapy sessions the same day of his appointment due to vague complaints; when he returned to session, he elaborated on these concerns with excessive detail in an attention-seeking manner. Similarly, his referral physician reported feeling compelled by Mr. X to treat him for unsubstantiated medical complaints.

Mr. X initiated his first session by describing the many “illustrious” mental health providers from whom he had received treatment. He described his goals for psychotherapy, which included growing his religious faith and practice, exploring lifelong questions regarding intimacy, and increasing the size of his social network. Mr. X engaged in two years of individual cognitive-behavioral therapy marked by numerous distractions that impaired his ability to focus on broader values-based treatment goals. Although efforts were made to assist him in gaining insight into the way in which personality factors influenced behavioral patterns and interpersonal difficulties, Mr. X benefitted primarily from concrete treatment approaches designed to address specific behavioral problems (i.e., poor adherence to medical recommendations).

Ms. Y is a middle-aged, Caucasian female who was referred by her oncologist for evaluation and management of distress in the context of diagnosis and treatment of cancer. Ms. Y presented for cancer treatment from out-of-state after seeking treatment recommendations from multiple well-known cancer centers throughout the United States. She was reportedly counseled by each facility that seeking multiple opinions would delay treatment and result in disease advancement and shortened survival. One center declined to treat her, as they believed that she did not seem able to engage in a collaborative relationship with medical team members. Once Ms. Y began treatment at our facility, she sought medical care for vague or minor symptoms from almost every department in our medical center. While her cancer diagnosis and potential side effects of treatment were well-documented, Ms. Y demonstrated a pattern of attention-seeking behavior, similar to that displayed by Mr. X, in which hypervigilance about minute changes in physical sensation or function were treated like emergencies that required urgent care. Ms. Y’s social history was remarkable for having a young child of whom she lost custody, multiple ex-boyfriends with whom she had tumultuous relationships, a current boyfriend, and a very supportive mother. Ms. Y reported receiving but not completing graduate medical training. Medical record review revealed the additional history that she was dismissed from graduate training and barred from seeking a health care practitioner license in several states due to academic and professional behavior issues.

Features of a personality disorder emerged within minutes of beginning Ms. Y’s intake in our training Clinic. Once settled in the interview room, Ms. Y called the trainees “incompetent,” and insisted that she would only see “the Attending.” Once the Attending Psychologist entered the room, she cried out loudly that she felt as if she had been sexually victimized. Upon clarification, she explained that this was in reference to being asked by a male health care provider to disrobe and change into a medical gown for a CT scan several months ago. This highly atypical and dramatic presentation, in conjunction with her reported history of exceptionally volatile interpersonal relationships, immediately alerted our team to the high likelihood of the presence of a severe personality disorder. Our medical record review and diagnostic interview yielded concrete evidence in support of a personality disorder diagnosis with prominent NPD features. Ms. Y provided a plethora of personal anecdotes, which further supported this diagnosis. Conceptualizing her case from within an NPD framework brought awareness and appreciation of the unique challenges of working with individuals with this disorder. This was a crucial initial step toward assisting Ms. Y with her primary goal of achieving and maintaining the interpersonal stability necessary to complete cancer treatment. Her self-reported history and behavior in the Clinic were consistent with key features of NPD, including relational volatility, excessive demands for special treatment, disdain for others’ emotional experiences, and lack of empathy. Moreover, her tendency toward hypersensitivity and negative automatic thought patterns regarding perceived insults from most individuals with whom she came into contact, including medical providers with whom she needed to collaborate in order to obtain life-preserving cancer treatment, resulted in persistently paranoid ideation. These symptoms of NPD caused her distress and served as barriers to obtaining successful medical and psychological treatment. As an aside, Mr. X demonstrated similar tendencies toward paranoia in terms of presuming that even subtle changes within the dynamics of existing interpersonal relationships were indicative of negative underlying motivations on the part of others. For both patients, this resulted in volatile relationships in personal and medical contexts.

Interestingly, Ms. Y herself confirmed a prior personality disorder diagnosis—which she referred to as “mixed personality disorder” with narcissistic features—within the context of discussing her history of difficult relationships with medical providers. However, Ms. Y did not provide specific information as to when, by whom, or under what criteria she had received this diagnosis. Ms. Y also disclosed anxiety about maintaining collaborative relationships with her treatment team. She expressed uncertainty about her ability to manage her distress related to her diagnosis, grief over interpersonal losses, and worry about the effects of cancer and treatment on her self-esteem, body image, and sexual functioning. Given that Ms. Y intended to move back to her residence in another state upon completion of her cancer treatment, brief therapy was indicated. The main goal of treatment was to increase Ms. Y’s capacity for distress tolerance so that she would be able to complete intensive cancer treatment. A secondary goal was to provide her with a positive psychotherapy experience in order to assist her with transitioning to longer-term psychological treatment upon her return home. She attended four, 50-minute, cognitive-behavioral therapy sessions. She achieved her goal of managing her distress in a manner that allowed her to complete her cancer treatment successfully. Given the brevity of the treatment that she received, we were unable to target major mood disturbance or core personality features. Thus, depression was not significantly reduced. However, she experienced a reduction in hopelessness and a remission in suicidal ideation during the course of her treatment. She also expressed that she had an overall positive experience in therapy and noted that she wished to pursue additional sessions upon return for routine follow-up care.

The following discussion highlights two crucial aspects of understanding NPD within Clinical Health Psychology practice: (1) how NPD manifests within psychotherapy in health care settings, and (2) specific ways in which these cognitive-behavioral patterns interfere with both medical and psychological treatment progress among individuals with NPD. Key ways in which NPD manifests in psychotherapy from a cognitive behavioral standpoint include: superlative self-talk and self-aggrandizement, expectations of special treatment, poor behavioral health adherence and difficult relationships with providers, and low distress tolerance. These aspects of the patients’ interpersonal style negatively affected treatment due to: poor boundaries with the therapist, ambivalence about change associated with fragile self-esteem, cognitive distortions (i.e., black-and-white thinking), and help-rejecting behaviors. An additional barrier to treatment progress underlying each of the above issues resulted from both patients’ tendency toward hypersensitivity and paranoia in therapy and in their everyday lives; both patients experienced interpersonal instability due to perceived insults and injuries of varying seriousness, which emphasized content that is clearly tied to core beliefs associated with narcissistic pathology.

Manifestations of NPD in brief and long-term psychological treatment

Superlative self-talk and self-aggrandizement.

Mr. X revealed a persistent pattern of self-glorification and a need to highlight his exceptional uniqueness in therapy. Over the course of his treatment, he repeatedly mentioned his “genius IQ,” his prodigious talents, and his exceptional ability to help others in need. Early in treatment he expressed concern regarding whether his therapist would be able to handle the complexities of his life story. He displayed a sense of self-satisfaction while relaying shocking, fantastical, or dramatic anecdotes from his life in which he often was the victim of disappointing circumstances or betrayal. He returned often to the idea that he was destined for some great purpose.

Ms. Y evidenced similar self-aggrandizement, including making frequent statements such as “I know I’m brilliant” and “I know more than [my medical providers] about my cancer treatment.” Her exaggerated self-worth was evident also in her perception of herself as highly sexually desirable to both men and women, especially those who are of high-status. Consistent with this, she reported a history of engaging in sexualized discourse and sexual relationships with health care providers and other professionals with whom she was under contract as well as a history of being sexually victimized/harassed by such individuals with pending litigation.

Expectation of special treatment

Mr. X repeatedly arrived 20 minutes early to his psychotherapy sessions seeking extra attention and lingering after his check-in to chat with Clinic staff. He frequently requested that the therapist extend his sessions, schedule additional sessions per week, and/or return multiple calls outside of session per week. Throughout treatment, Mr. X reminded the therapist about the celebrated health care providers with whom he had worked. He repeatedly compared his care to the services he received for many years at a prestigious medical school. He also noted even the slightest inconveniences he encountered at the Clinic, such as difficulty finding parking or not having a call returned quickly enough.

During treatment, Ms. Y would call at her appointment time to indicate that she would be 30 minutes late. However, when her appointment was rescheduled for that time, she would then arrive 30 minutes late to that appointment. As noted previously, she declined to receive services from pre-doctoral trainees due to their “incompetence” and expected that she would receive services solely from the Attending Psychologist, whose credentials she closely queried. Although she agreed to be treated by a postdoctoral trainee for therapy, she repeatedly advised the therapist that she found her care in the clinic unsatisfactory due to our department being “weak.” Expectations for special treatment extended to her cancer treatment team. Ms. Y demanded to receive cancer treatment on a federal holiday when the cancer center was closed. In addition, she used the oncology on-call service to obtain after-hours consultation about minor, nonurgent concerns, such as losing several tenths of a pound of weight.

Poor behavioral health adherence and difficult relationships with health care providers

Mr. X frequently failed to engage in self-care behaviors that were crucial to maintaining his health, such as dietary restrictions, CPAP usage, fluid intake management, consistent medication usage, and the wearing of compression socks. Additionally, Mr. X frequently alternated between idealizing and devaluating his physicians and their teams such that they were either at the top of their fields or completely inept. Mr. X often, to his own detriment, disagreed with his providers’ treatment plans and/or the manner in which they delivered care. For example, his cardiologist recommended that he discontinue use of a particular medication prior to completing a cardiac stress test. However, Mr. X decided that it would not be safe to stop using this medication. He also refused to complete the stress test due to concern that he would have a heart attack. Although Mr. X’s anxiety about the risks associated with this procedure was abundantly clear, he attributed his actions to superior knowledge of his body as compared to his medical providers.

Ms. Y sought multiple consultations regarding the management of her cancer, both prior to and during her treatment at our facility. She reported that several previous medical providers had discharged her from care due to her inappropriate behavior and an inability to form collaborative working relationships. She reported feeling abandoned by these providers, who she described as incompetent. She also noted that she filed complaints against them with state medical boards. At our facility, she was insistent upon receiving a new, highly specialized, and difficult-to-access cancer treatment. However, the oncology team at our facility did not recommend this treatment for her, which she repeatedly questioned and viewed as incompetence. This pattern of idealization and devaluation was also evident in therapy. When the therapist responded to Ms. Y’s suicidal ideation by conducting a risk assessment, Ms. Y stated that this was a waste of time and an indicator that the therapist was incompetent. Although the therapist was able to navigate these conflicts in a way that maintained the therapeutic relationship, Ms. Y continued to criticize the therapist and emphasize her dissatisfaction with her care.

In contrast to Mr. X, who struggled with adherence, Ms. Y was remarkably adherent to her cancer treatment and providers’ recommendations. This may have been at least partly due to the fact that her providers engaged her fully in her treatment planning and acknowledged and honored her objectively high level of knowledge about her cancer and its treatment.

Low distress tolerance

Mr. X demonstrated significant difficulty with tolerating ambiguous emotional experiences in which his self-worth was challenged. He frequently referred to difficult emotional experiences as “crises” and appeared to rely on the therapist rather than develop his own internal stress management skillset. Throughout treatment, Mr. X relayed multiple scenarios in which the experience of vulnerability in interpersonal relationships led to a pattern of emotionally charged, rapidly escalating encounters that almost always led to the demise of the relationship in question. Mr. X attempted to replicate this pattern several times with the therapist when he felt threatened by therapeutic challenges and/or boundary setting.

Similarly, Ms. Y was observed to experience difficulties with emotion regulation and distress tolerance. She described the possibility of not receiving the specialized cancer treatment that she was seeking as “the biggest regret of my life.” She indicated that routine clinical situations, such as being asked to disrobe and wear a hospital gown, were traumatic and sexually violating. Her affect was intense, dramatic in presentation, and out of proportion to events experienced. Her high level of distress prompted her to engage in excessive health care utilization and to expect that her concerns would be addressed immediately and fully. While undergoing medical treatment, she was experienced by clinical support staff on one occasion as aggressive and threatening. Outside of relationships with medical providers, Ms. Y endorsed a long history of volatile relationships with romantic partners, employers, and attorneys.

Challenges associated with NPD in psychological treatment

Poor boundaries.

Mr. X frequently challenged normative therapist-patient boundaries. He called the therapist excessively between sessions, requested extra time during his sessions, and insisted on giving the therapist a holiday gift. When presenting the therapist with a box of chocolates, Mr. X stated, “I know you are not supposed to accept presents, but you have no choice and will be taking that home with you.” He frequently made comments to the therapist in which he acknowledged a rule or boundary and then appeared to take pleasure in crossing these lines. Mr. X consistently treated the therapist overly informally, often complimenting her clothing, asking an increasing number of personal questions, or cursing during session.

Ms. Y also experienced difficulties with establishing and maintaining appropriate interpersonal boundaries in professional relationships. In particular, her rigidly held beliefs regarding the inferiority of a wide variety of groups of individuals threatened her ability to form respectful and effective relationships with diverse employers and health care providers. During her second therapy session, Ms. Y openly stated that the therapist’s country of origin and accent were problematic for her, noting that she had previously received substandard health care from individuals born outside the United States. The therapist used this opportunity to explore with Ms. Y how observing firm, prescribed boundaries with her health care providers could enhance her health care outcomes.

Ambivalence about change

Another prominent theme in Mr. X’s treatment revolved around his ambivalence regarding therapeutic change. Mr. X frequently asked the therapist to challenge him in certain ways and then responded negatively upon being challenged. When given therapy homework assignments, Mr. X frequently did not complete them; instead, he insisted on editing published worksheets, and/or amending the guidelines for prescribed exercises. He often identified therapeutic goals but strayed from them when discussions touched on painful subjects. Notably, Mr. X demonstrated particular difficulties with being interrupted. During some sessions, he lightheartedly noted that he was aware of his tendency to be verbose and gave the therapist “permission” to cut him off if he was being overly tangential. However, other times he became defensive and angry when the therapist attempted to redirect him without his permission. Mr. X’s inconsistent response to interruptions revealed a sense of ambivalence regarding his participation in the therapeutic process.

In contrast to Mr. X, Ms. Y expressed awareness of her personality structure and articulated strong motivation to mitigate her distress, complete her cancer treatment, and achieve future goals, such as seeing her child graduate from college. The value she placed on the role of motherhood, coupled with the life threat of a cancer diagnosis, appeared to be primary motivators for change.

Cognitive distortions

Consistent with firmly held beliefs about his specialness, Mr. X revealed a pattern of negative, all-or-nothing thought processes. He frequently struggled to see multiple perspectives on an issue and devalued others who were not able to see his perspective. This tendency resulted in a vicious cycle of unrealistic goal-setting, feelings of failure, and low mood which often impaired his ability to make progress in treatment.

Ms. Y also expressed a number of distorted beliefs about herself, her world, and her future. Her inflated self-concept did not appear to be grounded within objective academic, employment, or interpersonal histories. Additionally, she held many negative expectations of others based on distorted beliefs about how individuals from various socioeconomic, educational, and demographic backgrounds think, feel, and behave. These beliefs led to significant emotional dysregulation, poor distress tolerance, and interpersonal chaos with her medical providers and others in her life.

Help-rejecting behaviors

Mr. X frequently engaged in self-sabotaging behavior related to treatment goals. He cancelled almost the same number of scheduled sessions that he had completed over a two year period. He often maintained that the cancellations were due to medical exacerbations but later revealed that he was experiencing some sort of psychosocial distress. Mr. X also became angry with his medical providers due to his preoccupation with minor details regarding the speed and efficiency with which they served him. After a particularly emotional session during which the therapist encouraged Mr. X to explore his feelings surrounding one of his greatest life regrets, Mr. X called the Clinic and reported that he needed to speak to his therapist’s supervisor and to be assigned a new therapist. Mr. X lashed out at the therapist via her supervisor by questioning her competency. However, after several delicate discussions, Mr. X resumed work with the therapist. He spent months dramatically alluding to difficulties in trusting the therapist and the burden of rebuilding the therapeutic relationship.

Ms. Y’s pursuit and then rejection of cancer treatment recommendations from numerous cancer centers across the United States is consistent with help-rejecting behavior that occurs in NPD. However, once she decided to receive care at our facility, she was observed to be adherent to her treatment recommendations and actively engaged in her own care.

Summary of results

These cases demonstrate the complex relationship between manifestations of NPD and challenges to psychotherapeutic progress in a hospital-based clinical and health psychology practice. Mr. X and Ms. Y both demonstrated features of NPD during the course of their treatment. Mr. X indicated during his first session that he sought long-term psychotherapy in response to recovering from a medical crisis and re-evaluating his goals moving forward. Although he experienced many personality-based barriers to progress in psychotherapy, he was able to work through multiple therapeutic ruptures and maintain a strong relationship with the student therapist that was grounded in humor, authenticity, and direct communication. He also demonstrated some growth in personal insight regarding the ways in which his tendency toward black-and-white thinking affects his mood and daily function, particularly in terms of his relationships. However, in many ways, his dramatic and avoidant tendencies precluded his ability to make prominent changes in worldview or interpersonal style.

Ms. Y, on the other hand, entered treatment when in the throes of a perceived medical crisis due to distress associated with her cancer diagnosis and a lack of confidence in her ability to manage the complex emotions associated with a potentially life-threatening illness. At the time of her referral, her medical team’s primary goal was to reduce her stress and improve her emotion regulation enough that she would be able to engage in an appropriate manner with her medical team in order to successfully complete her cancer treatment. Unlike Mr. X, it did not appear as if Ms. Y sought long-term, deep, existential therapy that would allow her to explore her complex history or goals for the future. Therefore her treatment was more problem-focused in order to reduce barriers to successful cancer treatment.

As previously reflected, treatment challenges for patients with NPD in clinical health psychology include: (1) poor boundaries, (2) ambivalence about change, (3) cognitive distortions, (4) idealizing and devaluing providers, (5) poor behavioral health adherence, and (6) help-rejecting behaviors. Table 1 summarizes psychotherapy treatment challenges related to key features of NPD and identifies how these behaviors were demonstrated by each patient.

Behavioral examples of treatment challenges in clinical health psychology practice.

The cases discussed above highlight many prominent features of NPD as displayed by two patients receiving psychotherapy in a clinical health psychology practice within an academic teaching hospital. These patients shared a lifelong history of distress associated with unmet expectations, unrealized goals, and unfulfilling relationships. Both patients had sought psychotherapy and pharmacologic treatment throughout their lives and both presented to our clinic seeking support while dealing with chronic and potentially life-limiting illnesses. While there were many shared experiences between these two patients, there were some crucial differences. Mr. X explicitly sought long-term supportive therapy, while Ms. Y engaged in brief, problem-focused treatment. Mr. X was socially isolated and estranged from all living family members, while Ms. Y maintained a close, emotionally supportive relationship with her mother. Additionally, Mr. X demonstrated significant resistance to behavior change as manifested by inconsistent attendance, poor homework completion, avoidance of emotionally difficult topics, and lashing out at the therapist when he felt she had offended him. However, Ms. Y was motivated and receptive to treatment. Although her depressive symptoms did not resolve over the course of her brief treatment, her sense of hopelessness and suicidal ideation both decreased.

These cases highlight the complex experiences of individuals with NPD and those who work with them in clinical settings. The similarities in these cases offer support for core features of NPD as a unique condition, while the differences in their life experiences is suggestive of the variability that may affect psychological treatment course and outcomes. Mr. X made some progress on therapeutic goals but continued to be limited in his ability to engage on a deeper level due to ongoing medical management issues and psychological avoidance. Ms. Y terminated treatment after four sessions. However, psychological treatment may have played a crucial role in her ability to manage distress while enduring the challenges of cancer treatment.

A prominent challenge in the conceptualization of NPD cases revolves around the heterogeneity in presentation of the disorder and significant symtomatologic overlap with other Cluster B personality disorders. In particular, the DSM-5 Cluster B disorders share significant symtomologic overlap in terms of excessive attention-seeking, emotion dysregulation (i.e., impulsive rage), inappropriate sexual behavior, and unstable views of others (i.e., fluctuating between idealizing and devaluing). 1 Consistent with this, although NPD diagnoses were favored for Mr. X and Ms. Y, both demonstrated features of Histrionic Personality Disorder, Borderline Personality Disorder, and Antisocial Personality Disorder. However, both patients’ most prominent, distressing, and impairing symptoms and behaviors were those that are unique to the DSM-5 diagnostic criteria for NPD (i.e., arrogance, grandiosity, and need for admiring attention). Further, both patients demonstrated a relative stability of self-image, a relative absence of deceit, and a relative lack of conduct disorder/criminal history, 1 suggesting an absence of several defining features of Borderline Personality Disorder and Antisocial Personality Disorder. As such, NPD diagnoses appeared to best account for these patients’ distress and impairment at the time of presentation for treatment. However, it is possible that other Cluster B disorders may be more prominent for these patients in different circumstances (i.e., health vs. family stressors).

Conclusions

The diagnostic framework used to explore pathological narcissism in the above cases was organized according to the DSM-5 criteria. 1 These criteria were developed with an underlying assumption that personality disorders can be characterized into independent clusters and independent clinical syndromes. Recent consideration has been given to an alternative model. Working under the assumption that personality disorders have significant clinical overlap, the dimensional approach argues that pathological personality features may represent a wide range of fluid presentations that begin with normal personality function. This alternative model is explicated in an appendix to the DSM-5 and describes the ways in which personality function may vary between individuals on four dimensions: Identity, Self-Direction, Empathy, and Intimacy. Additionally, further consideration is made regarding personality function on five dimensional scales: negative affectivity, detachment, antagonism, dis-inhibition, and psychoticism. 1 The exploration of these dimensional scales may allow clinicians to conceptualize patients in a way that they are able to work around limitations in categorical diagnostic criteria in order to improve the likelihood of symptom reduction and improved quality of life.

A brief reconceptualization of Mr. X and Ms. Y’s histories from within the new model of personality disorders allows us to examine their personalities within the domains described and to rate their level of dysfunction from 0 (Little or no impairment) to 4 (Extreme Impairment). This system allows clinicians to assess symptoms at multiple levels of emotional function rather than being forced to identify a single disorder that captures the entirety of the patient’s history and present difficulties. This system is also useful in addressing the problem of overlap among within-cluster disorders.

Overall these case studies and the literature reviewed highlight: (1) the importance of provider familiarity with personality disorder symptom profiles and evaluation, (2) the significance of personality disorders in affecting medical and psychological treatment course and outcomes, (3) the potential impact of treating personality disorders on provider function and well-being, and (4) potential future directions for research on how to improve treatment outcomes for individuals with personality disorders, and NPD specifically, where obstacles to forming the crucial therapeutic alliance may have a critical impact on patient prognosis.

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• Published: 03 August 2021

Narcissistic personality traits and prefrontal brain structure

• Igor Nenadić 1 , 2 , 3 ,
• Carsten Lorenz 3 &
• Christian Gaser 3 , 4  

Scientific Reports volume  11 , Article number:  15707 ( 2021 ) Cite this article

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• Brain imaging
• Human behaviour
• Social neuroscience

Narcissistic traits have been linked to structural and functional brain networks, including the insular cortex, however, with inconsistent findings. In this study, we tested the hypothesis that subclinical narcissism is associated with variations in regional brain volumes in insular and prefrontal areas. We studied 103 clinically healthy subjects, who were assessed for narcissistic traits using the Narcissistic Personality Inventory (NPI, 40-item version) and received high-resolution structural magnetic resonance imaging. Voxel-based morphometry was used to analyse MRI scans and multiple regression models were used for statistical analysis, with threshold-free cluster enhancement (TFCE). We found significant ( p  < 0.05, family-wise error FWE corrected) positive correlations of NPI scores with grey matter in multiple prefrontal cortical areas (including the medial and ventromedial, anterior/rostral dorsolateral prefrontal and orbitofrontal cortices, subgenual and mid-anterior cingulate cortices, insula, and bilateral caudate nuclei). We did not observe reliable links to particular facets of NPI-narcissism. Our findings provide novel evidence for an association of narcissistic traits with variations in prefrontal and insular brain structure, which also overlap with previous functional studies of narcissism-related phenotypes including self-enhancement and social dominance. However, further studies are needed to clarify differential associations to entitlement vs. vulnerable facets of narcissism.

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Narcissism refers to a set of personality traits incorporating cognitive, emotional, and behavioural features, which are commonly conceptualised around facets of grandiosity, entitlement, and vulnerability 1 , 2 , 3 . Current conceptualisations of narcissism therefore consider a bipolarity of grandiose vs. vulnerable narcissism or multipolarity of major facets, often evolving around deficits in maintaining functional levels of self-esteem, with such traits being common in the general population and not uniformly linked to dysfunction or distress 2 .

Narcissistic traits have been studied both in social or personality psychology as well as clinical contexts, especially with reference to narcissistic personality disorder (NaPD) 4 , 5 , 6 . While the case has been made that clinical research on narcissistic personality disorder might benefit from data obtained in non-clinical studies of narcissistic traits 7 , the relation between the conceptualisations in these two different lines of research is by no means clear and a matter of ongoing debates and research 3 , 6 , 8 . In the subclinical range, narcissistic traits can be associated with positive effects in initial group formation and leadership, but often lead to adverse interactional outcomes over time 9 , 10 .

Psychometric characterisation of the narcissistic phenotype in general population cohorts has relied on well-established and validated questionnaires, in particular the Narcissistic Personality Inventory (NPI) by Raskin and Hall 11 , which considers aspects of grandiosity, as well as leadership and entitlement 12 , 13 , 14 , 15 , 16 . Hence, while alternative more recent scales have become available 16 , 17 , 18 , the NPI still remains a widely used instrument 19 , 20 with a large database of studies 21 , 22 .

Given the relevance of narcissism in both clinical and non-clinical research fields, there is an astonishing paucity of neuroscience research relating narcissistic traits or behaviours to either brain function or structure. A pioneering explorative functional magnetic resonance imaging (fMRI) study comparing 11 high-narcissistic vs. 11 low-narcissistic subjects using an empathy paradigm implied decreased deactivation in the right anterior insula in the high-narcissism group 23 , an area implicated in cognitive empathy 24 , 25 , 26 , which can be considered a main factor in developing prosocial behaviours 27 , 28 . Further functional studies have found correlations of narcissistic traits in clinically healthy subjects in anterior insula and dorsal anterior cingulate and subgenual cingulate cortices during tasks involving social rejection 29 , as well as elevated dorsal anterior cingulate cortex (dACC) response to social rejection stimuli 30 and self-related visual stimulus processing 31 . In an EEG study, feed-back related negativity in midline frontal areas in an EEG study did not differ between low vs high narcissistic subjects, but a difference in centro-parietal P3 emerged 32 . Together with studies implicating impaired structural white matter connectivity in frontostriatal tracts 33 , this gives rise to (anterior) insula and prefrontal (esp. dACC) involvement in narcissistic behaviours.

In contrast to these cues from functional imaging studies, there is no clear evidence on the brain structural underpinnings, esp. for grey matter. One previous study using cortical thickness measurements reported a negative correlation of PNI (pathological narcissism inventory) scores with right dorsolateral and inferior prefrontal thickness, and cortical volumes in the left medial prefrontal and right dorsolateral prefrontal cortices 34 , while another showed an interaction of gender and NPI scores in the right superior parietal cortex using voxel-based morphometry 35 .

The present study was conducted to test the association of brain structure and narcissistic traits in a non-clinical cohort. In particular, we tested the hypothesis that subclinical narcissistic traits (assessed with the NPI) would be correlated with prefrontal brain structures (as implicated in functional studies and one of the preceding cortical mapping studies) as well as the (anterior) insula. We chose a whole-brain voxel-wise analysis for spatial resolution to distinguish between different areas of the orbital, medial, and lateral prefrontal cortices.

Study cohort and phenotyping

For this study, we analysed data from a total of 103 psychiatrically healthy subjects (53 female, 50 male) recruited from the local community. All participants gave written informed consent to study participation as part of a study protocol approved by the local ethic committee of the Medical School of Friedrich-Schiller-University of Jena, in accordance with the Declaration of Helsinki in its current version. Inclusion criteria were age 18–65 years and ability to provide informed consent, while exclusion criteria were any concurrent or previous psychiatric disorder (including current substance dependence) central nervous neurological disorders (including traumatic brain injury/loss of consciousness), or learning disability/IQ lower than 80, as well as intake of psychotropic medication.

Subjects were screened for absence of exclusion criteria, in particular any previous treatment for psychiatric disorders. IQ was estimated using the MWT-B (Mehrfachwortschatztest B; 36 , 37 ), and while IQ scores lower 70 would be considered suggestive of a learning disability, we defined an exclusion threshold of 80 to take into account imprecisions and potential overestimations of this screening test (ultimately, however, none of our recruited subjects was excluded as the minimum detected IQ in this sample was 88). Following screening and formal inclusion, subjects underwent MRI scanning and phenotyping for narcissistic traits.

We used the narcissistic personality inventory NPI 11 , applying the full 40-item validated German version 38 , to characterise our sample for narcissistic traits. The NPI has been used in a large number of studies 20 , 39 , including non-clinical and clinical samples, as well as several of the functional imaging studies cited above. While validity studies of the NPI by Raskin and Terry suggested seven components defined as authority, exhibitionism, superiority, vanity, exploitativeness, entitlement, and self-sufficiency 40 , there have been alternative accounts of four factors labelled exploitativeness/entitlement, leadership/authority, superiority/arrogance, self-absorption/self-admiration 15 , and more recently of two or three factors assigned ‘power’, ‘exhibitionism’, and ‘special person’ 41 . In particular, Ackerman and colleagues in a recent re-appraisal of the NPI including analyses of large college student samples 12 , advocated a three-factor model (with facets: leadership/authority, grandiose exhibitionism, and entitlement/exploitativeness). Based on findings of the validation study and factorial analysis of the German NPI translation 38 , we calculated additional seven NPI subscales designated (sample items in brackets refer to the original NPI text in English): authority (8 items, e.g.: “I am a born leader”), entitlement (6 items, e.g.; “I insist upon the respect that is due me.”), exhibitionism (7 items, e.g.: “Modesty doesn’t become me.”), exploitativeness (6 items, e.g.: “I can make anybody believe anything I want them to”), self-sufficiency (6 items, e.g.: “I rarely depend on anyone else to get things done.”), superiority (5 items, e.g.: “I think I am a special person.”), vanity (3 items, e.g.: “I like to look at myself in the mirror”).

Demographic and psychometric data of the sample are summarised in Table 1 .

Magnetic resonance image (MRI) acquisition

MRI scanning was done on a 3 Tesla Siemens Tim Trio system (Siemens, Erlangen, Germany) using a T1-weighted high-resolution MPRAGE sequence (magnetisation-prepared rapid gradient echo) with a standard quadrature head coil (scanning parameters: TR 2300 ms, TE 3.03 ms, flip angle α 9°, in-plane field-of-view 256 mm) acquiring 192 contiguous sagittal slices covering the whole brain. Scanning duration was 5:21 min. All scans were visually inspected after scanning for gross artefacts (e.g. movement, ghosting), and all scans passed this initial step of quality assurance.

Voxel-based morphometry

We used a voxel-based morphometry (VBM) approach to analyse T1 scans, using Statistical Parametric Mapping (SPM) software (Wellcome Institute of Imaging Neuroscience, Institute of Neurology, London, UK) running on Matlab (Mathworks, Natik, MA, USA) and the VBM8 toolbox, r435 (C. Gaser, Jena University Hospital; http://www.dbm.neuro.uni-jena.de/vbm/vbm8 ), as in two previous studies of personality traits and narcissistic personality disorder, respectively 42 , 43 . Our processing pipeline have been described previously (e.g. 43 ), including augmentation of segmentation through accounting for partial volume effects 44 , adaptive maximum a posteriori estimation 45 , and hidden Markov Random Field models 46 . All scans passed the automated quality assurance protocol in VBM8. After segmentation of grey matter maps, we applied an internal grey matter threshold of 0.2, in order to eliminate potential artefacts at ambiguous grey matter borders; this threshold is more conservative than the often used 0.1 GM threshold. Anatomical labelling was available with the AAL atlas 47 .

Statistical analysis

For all VBM statistical analysis, we used threshold-free cluster enhancement (TFCE), an approach introduced to increase sensitivity of voxel-based analyses 48 , 49 , applying 5000 permutations (Smith method).

First, we tested our main hypothesis of brain structural associations with NPI scores using a general linear model (GLM) in SPM with NPI total score as regressor and age and sex as nuisance variables (in order to remove age and sex related effects). Based on TFCE, we then used a p  = 0.05 family-wise error (FWE) correction to correct for multiple comparisons across whole-brain GM voxels, testing for both positive and negative correlations. NPI skewness of 0.411 was in an acceptable range for this statistical approach.

Second, we followed up our main analysis by testing the hypothesis of sex interactions, i.e. that correlation slopes might differ significantly between female and male study participants. For this purpose, we set up a new GLM, again using age as a regressor, to reveal areas in which female subjects would show a higher/steeper increase over males and vice versa. This analysis aimed at replicating the previous finding 35 of sexually dimorphic associations for the parietal cortex in a VBM study (with unclear main effects of NPI total scores).

The exploratory nature of this analysis acknowledges limited statistical power in these (smaller) subgroups of the study cohort, as well as interaction effects in VBM often being more difficult to detect given lack of sensitivity even in decent sized samples.

Third, we performed exploratory analyses testing for potential associations of the seven NPI subscales with brain structure, defining separate GLMs, each including the respective NPI subscale, as well as age and sex as nuisance variables.

Associations of NPI total score with brain structure

In our main analysis, we found significant ( p  < 0.05, FWE-corrected, TFCE) positive correlations NPI total scores with regional brain grey matter volume in four clusters including bilateral medial, orbital, and dorsolateral prefrontal as well as left insular cortices (see Figs.  1 and 2 ).

Voxel-based morphometry (VBM) analysis showing positive correlations of narcissistic personality inventory (NPI) total score with grey matter (TFCE analysis, p  < 0.05 FWE corrected, axial sections with z levels given beneath each section) (Image created using the VBM8 toolbox, version r435; C. Gaser, Structural Brain Mapping Group, Jena University Hospital, Jena, Germany; http://www.dbm.neuro.uni-jena.de/vbm/vbm8 ).

Voxel-based morphometry (VBM) analysis showing positive correlations of narcissistic personality inventory (NPI) total score with grey matter (TFCE analysis, p  < 0.05 FWE corrected, coronal sections with y levels given beneath each section) (Image created using the VBM8 toolbox, version r435; C. Gaser, Structural Brain Mapping Group, Jena University Hospital, Jena, Germany; http://www.dbm.neuro.uni-jena.de/vbm/vbm8 ).

Of the four significant clusters, the first cluster spanned a large confluence of regions mostly covering the prefrontal areas (cluster size k = 15,419, maximum intensity voxel at MNI space co-ordinates 10; 39; − 14 with p FWE-corr  = 0.005, with additional local maxima at 10; 47; − 20 and − 21; 24; 6 – both at p FWE-corr  = 0.006).

Additional clusters were k = 1377 voxels (maximum intensity voxel at − 12; 18; 48 with p FWE-corr  = 0.035; additional local maxima − 9; − 15; 60 with p FWE-corr  = 0.036 and − 3; − 4; 52 with p FWE-corr  = 0.037), and smaller clusters with k = 178 voxels (maximum intensity voxel at − 30; 9; 40 with p FWE-corr  = 0.045; additional local maxima 32;8;49 with p FWE-corr  = 0.047 and − 30; 11; 57 with p FWE-corr  = 0.047) and k = 102 voxels (maximum intensity voxel at − 44; 27; 7 with p FWE-corr  = 0.047), respectively, with clusters extending towards bilateral caudate nuclei.

Interaction effects with NPI total scores

We did not identify a significant interaction effect of sex and NPI total scores on brain structure at corrected thresholds ( p  < 0.05, FWE-corrected, TFCE) apart from one single voxel in the right lateral prefrontal cortex (k = 1; 58; 22; 3, p FWE-corr  = 0.05) with higher correlation slopes in women. In particular, we did not identify any sex-by-NPI interaction in the superior parietal cortex, as implicated in a previous study 35 .

In further exploratory analysis at uncorrected threshold levels ( p  < 0.001, uncorr.), women showed steeper positive correlations with NPI total scores than men in two right dorsolateral prefrontal clusters (k = 930; maximum intensity voxel 58; 22; 3; and k = 233; 36;26;28) and one in the right posterior parietal/occipital cortex (k = 116; 30; − 81; 40) and one single voxel at 8; − 25; 73. There were no inverse effects (i.e. steeper slopes in men compared to women) even at p  < 0.001 uncorrected thresholds.

Comparison of psychometric data between female and male participants did not show significant group-level differences, apart from one single scale with male subjects scoring higher on the NPI subscale entitlement (T-test: T = 2.898, p  = 0.005; assuming unequal variances based on Levene-test F = 11.154, p  = 0.001), and trend-level findings for higher values of total NPI score in male subjects (T-test: T = 1.749, p  = 0.083; assuming equal variance based on Levene-text F = 0.19, p  = 0.664), and higher values for NPI subscale authority in male subjects (T-test: T = 1.956, p  = 0.053; assuming unequal variances based on Levene-test F = 4.216, p  = 0.043).

Exploratory analysis of brain structure and NPI subscales

Exploratory analysis of the seven NPI subscales (authority, entitlement, exhibitionism, exploitativeness, self-sufficiency, superiority, vanity) revealed only small minor clusters in the following associations (only those with k > 15 reported): (a) for exhibitionism a positive correlation with two clusters in the left parietal lobe (k = 124; maximum at – 36; − 40; 52 with p FWE-corr  = 0.047) and right medial parietal/cingulate cortex (k = 17; maximum at 12; − 28; 33 with p FWE-corr  = 0.048), (b) for self-sufficiency a positive correlation with a cluster in the left medial prefrontal cortex (k = 84; maximum at – 10; 12; − 11 with p FWE-corr  = 0.048), (c) for superiority a positive correlation with a left anterior/rostral prefrontal cluster (k = 308; maximum at − 21; 56; 21 with p FWE-corr  = 0.032). However, we did not identify any other significant association on the brain structural level at p FWE-corr  < 0.05 levels. While this exploratory analysis initially used uncorrected p  < 0.001 thresholds, it is noteworthy that none of the above clusters would survive Bonferroni adjustment for multiple comparisons (across multiple GLMs).

The present study set out to test the hypothesis that subclinical narcissistic traits in a nonclinical population would be associated with brain structural variation of grey matter, esp. in prefrontal systems. And indeed, our findings provide evidence of a correlation of prefrontal cortical grey matter with NPI narcissism. Our interpretation of results is directed at the three main aspects of the study: first, the implication of insular and prefrontal cortical regions (including orbitofrontal, ventromedial/medial prefrontal, and dorsolateral prefrontal areas) towards a neurobiological model of narcissistic traits; second, the relation of our findings to the (limited) imaging studies in clinical narcissistic personality disorder (NaPD); and thirdly, an overlap of our findings with studies of related behavioural traits, such as social dominance or self-enhancement, which map to some of the identified regions.

Our findings extend the previous structural association studies of narcissism (measured with the PNI) and reduced right dorsolateral prefrontal thickness 34 by showing a (positive) correlation with a more widespread network of prefrontal areas including the medial/ventromedial and orbitofrontal cortices, subgenual anterior cingular as well as insular cortices. It is therefore the first to suggest multiple widespread prefrontal networks to be involved in the narcissistic phenotype. This is of relevance, esp. given a previous VBM study failing to demonstrate such an association 35 . This seems plausible, also given the multiple facets of narcissism on the phenotype level 1 , 50 , which do not make convergence on a single neuroanatomical region/network plausible. In fact, the insular finding potentially links our finding to both studies of cognitive empathy 27 , 51 , 52 as well as to studies in patients with clinical narcissistic personality disorder 52 . However, the latter study, similar to another pilot study in NaPD 42 , only had small sample sizes, and rather hinted to a lateral prefrontal deficit. It is worthwhile noting that, unlike the clinical studies, our findings showed a positive , rather than negative, correlation of the narcissistic phenotype with brain volumes. It is interesting to note that comparable VBM studies of nonclinical population assessing subclinical phenotypes, for example irritability/hostility 53 or impulsivity 54 have shown such positive correlations and it has been suggested that this might be due to a non-linear association across a broader continuum (from nonclinical to pathology), of which only a small proportion would be assessed in a nonclinical study; hence, if narcissism, like irritability or hostility would show an inverted-U-shape relation across the whole nonclinical-to-clinical spectrum, a study in the lower to mid nonclinical range might show positive correlations (see, e.g. 53 ). An additional interpretation might be that some aspects of narcissistic traits in a low expression, might be beneficial or even desirable in a particular (e.g. competitive) social context, but our lack of relevant social or other personality data in this sample does not allow for further testing in this particular cohort.

In comparing our findings to the literature, we also need to consider differences across narcissism inventories: in contrast to the NPI, the PNI focuses more on pathological narcissism, with a more thorough focus on vulnerable facets, which might be more closely associated with clinically relevant phenotypes (for discussion, see 3 , 8 , 55 ).

The discrepancies to the two previous nonclinical association studies using the PNI 34 and NPI 35 , respectively, might additionally be explained by data analysis methodology as well as culturally different expressions (e.g., see 56 ).

While our study only assessed brain structure, there are several links to functional imaging studies pertinent to aspects of the narcissistic phenotype, which link our findings to prefrontal and insular networks to the expression of relevant behaviours. One of these is social rejection, which has been related to networks including the anterior insula, dorsal ACC and subgenual ACC 29 —part of which also featured prominently in our findings. Similarly, a recent study on cognitive emotion regulation training demonstrated that vmPFC activity exerts a modulated emotional response in regulating emotions to aversive images 57 , which connects our study to previous hypotheses of deficient emotion regulation in narcissism and prefrontal brain networks. The mPFC, also identified in our study, has previously been linked to self-enhancement in a series of brain stimulation studies 58 , 59 , 60 .

Given the relative paucity of imaging studies of narcissistic traits in the narrow sense, we should like to point out that several previous studies have linked medial PFC structure and activity to social functions, especially pertaining to social dominance and self-enhancement. The “dominance behavioral system”, which has been linked to narcissistic and manic temperament phenotypes 61 , 62 provides such a framework. In fact, at least two recent fMRI studies of social dominance and hierarchies show brain activation foci in location similar to findings of our study: one showed social hierarchy processing in an anterior dorsolateral prefrontal cluster, slightly dorsal in localisation to our anterior prefrontal clusters 63 , while another showed modulation of dominance and subordination to a medial prefrontal/bilateral caudate network 64 . While the latter in particular are consistent with more general conceptualisations of biological dominance, it should be pointed out that this inference is indirect at best, and that this interpretation should be considered with caution. It should, however, be noted that networks involving mPFC activity have consistently been linked to socially dominant behaviours even across a more general biological conceptualisation of this phenotype across species 27 , 65 , 66 , 67 , 68 , which warrants further studies of its overlap with the narcissistic phenotype studied in our sample.

Our study only found minor interactions of sex and narcissism in its relation to brain structure. While we need to consider that our sample showed only minor differences in narcissism (sub)scales between females and males, it might lack generalisability in that respect (as gender differences have been shown in large meta-analyses 21 ). The few findings of a sexually dimorphic effect were, however identified in the lateral prefrontal cortex and thus no effects or trends were observed in medial prefrontal, orbitofrontal, or insular cortices.

Finally, we need to consider a few limitations of our study, including the moderate sample size, which is also a potentially limiting factor in identifying sex interactions and correlations to those subscores, which are based on a smaller number of NPI items, as well as the lack of functional MRI analyses. While our choice of the NPI was guided based on its wide-spread application in the past, it might not cover some aspects of narcissism as well as other inventories, and further studies are needed to differentiate the contribution of, for example, entitlement vs. vulnerability to the different prefrontal network nodes. Despite our support for prefrontal involvement in narcissism, the current evidence across the few available studies is not unequivocal, and additional studies using more fine-grained phenotyping as well as possibly additional imaging modalities are needed to further corroborate the available evidence, which is non unequivocal.

One major limitation is specificity: as our phenotyping only included the NPI, which defines a complex, multi-faceted narcissism phenotype, we cannot exclude the possibility that other, less-specific factors or even traits unrelated to narcissism (e.g. neuroticism) might similarly have explained variance in the identified brain structure. Further studies with more in-depth phenotyping would be necessary to ascertain specificity and better characterise which singular facets of narcissism or related traits might drive the associations to different brain areas, esp. across the prefrontal cortex. Nevertheless, our study is a potentially important advance over previous studies, as it shows for the first time, using a robust imaging and statistical approach, that multiple prefrontal and insular cortical areas are correlated with the expression of narcissistic traits, even in the absence of manifest pathology.

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Acknowledgements

Parts of this study were supported by a Junior Scientist Grant of the Friedrich-Schiller-University of Jena (to I.N.). We would like to thank all colleagues at the Department of Psychiatry and Psychotherapy in Jena for their help and assistance with subject recruitment and scanning, in particular Dr. Kerstin Langbein and Dipl.-Psych. Maren Dietzek, who both contributed immensely to the lab’s MR studies, from which this cohort was drawn, as well as the technicians of the Institute of Diagnostic and Interventional Radiology, Jena University Hospital, for their help with scanning.

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Igor Nenadić, Carsten Lorenz & Christian Gaser

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I.N. conceived of the study and its design, obtained funding, supervised recruitment, MRI scanning and data analysis, interpreted data, and wrote the manuscript. C.L. analysed MRI data under supervision. C.G. supervised MRI data analysis and consulted on methodology. All authors commented on the first draft and approved of the final version of the manuscript.

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Nenadić, I., Lorenz, C. & Gaser, C. Narcissistic personality traits and prefrontal brain structure. Sci Rep 11 , 15707 (2021). https://doi.org/10.1038/s41598-021-94920-z

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DOI : https://doi.org/10.1038/s41598-021-94920-z

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Narcissistic personality disorder (NPD) is a pervasive pattern of grandiosity, a need for admiration, a lack of empathy, and a heightened sense of self-importance. Individuals with NPD may present to others as boastful, arrogant, or even unlikeable. NPD is a pattern of behavior persisting over a long period and through a variety of situations or social contexts and can result in significant impairment in social and occupational functioning. Additionally, NPD is often comorbid with other psychiatric illnesses, which may further worsen independent functioning. Unfortunately, treatment modalities for NPD are limited in both availability and efficacy.

The term narcissism was first described by the Roman poet Ovid in his work Metamorphoses: Book III . This myth centers around Narcissus, a character cursed to fall in love with his reflection. However, it was not until the late 1800s that narcissism was used to define a psychological mind state.

The psychologist Havelock Ellis first used the term narcissism in 1898 to link the description of Narcissus to behaviors he observed in his patient. Shortly after, Sigmund Freud labeled "narcissistic libido" in his book Three Essays on the Theory of Sexuality . Psychoanalyst Ernest Jones described narcissism as a character flaw. In 1925, Robert Waelder published the first case report of pathological narcissism and described it as "narcissistic personality." Despite these developments, NPD was not included in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I). It was not until 1968, during the era of the second edition of the DSM (DSM-II), that Heinz Kohut termed narcissism.

In the DSM, personality disorders have been categorized into clusters based on shared characteristics; this model persists into the current DSM (fifth edition, text review) (DSM-5-TR). This categorization includes cluster A, cluster B, and cluster C personality disorders.

Cluster A: Personality disorders with odd or eccentric characteristics, including paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder

Cluster B: Personality disorders with dramatic, emotional, or erratic features, including antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder

Cluster C: Personality disorders with anxious and fearful characteristics, including avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder

Despite the historical context of using the cluster system, there are limitations when approaching personality disorders in this manner, and it is not consistently validated in the literature.

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Disclosure: Tyler Torrico declares no relevant financial relationships with ineligible companies.

Disclosure: Dimy Fluyau declares no relevant financial relationships with ineligible companies.

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