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. Author manuscript; available in PMC: 2020 Sep 1.
Published in final edited form as: Personal Disord. 2019 Jul 1;10(5):473–478. doi: 10.1037/per0000347

Pathological Narcissism and Psychosocial Functioning

Samantha C Dashineau 1, Elizabeth A Edershile 2, Leonard J Simms 3, Aidan GC Wright 2
PMCID: PMC6710132  NIHMSID: NIHMS1035949  PMID: 31259606

Abstract

Pathological narcissism involves maladaptive efforts to regulate the self, and is conceptualized by two key features: narcissistic grandiosity and narcissistic vulnerability. Prior research has found that narcissism is associated with poorer functioning over the long term, especially interpersonal functioning. Despite this, the specific contributions of grandiosity and vulnerability to different domains of functioning remain understudied. In particular, there has been scant literature investigating pathological narcissism and its effects on functioning in large clinical samples. Understanding how grandiosity and vulnerability each contribute to dysfunction will help inform the conceptualization, prognosis, and treatment recommendations, alike, for narcissism. This study examined the relations between narcissism and different domains of dysfunction in a sample of 288 current or recent psychiatric outpatients. Results suggest that narcissistic grandiosity is associated with specific deficits in interpersonal functioning, whereas vulnerability is associated with all forms of dysfunction. However, once accounting for shared variance in grandiosity and vulnerability, vulnerability continues to be predictive of all forms of dysfunction, whereas grandiosity serves as a modest protective factor.

Keywords: Narcissistic Personality Disorder, Narcissistic Grandiosity, Narcissistic Vulnerability, Dysfunction

Pathological Narcissism and Psychosocial Functioning

Pathological narcissism can be quite debilitating and leads to serious consequences (Ansell et al., 2015; Ellison et al., 2013; Pincus et al., 2009). It is generally agreed that pathological narcissism is dimensional (Aslinger et al., 2018), and that its manifestations can be divided in to two core themes—narcissistic grandiosity and narcissistic vulnerability. Narcissistic grandiosity is characterized as an exaggerated sense of uniqueness, immodesty, and a desire for high praise by others (Cain, Pincus, & Ansell, 2008; Miller et al., 2017). Narcissistic vulnerability involves experiences of deep shame regarding needs, expectations, and threats to self-esteem (Dickinson & Pincus, 2003; Pincus & Lukowitsky, 2010). Despite the disparate phenotypic presentations of grandiosity and vulnerability, both share features of antagonism and entitlement (Miller et al., 2017; Krizan & Herlache, 2018) and reflect the overall goal of maintaining a positive self-image through validation, self-enhancement, and defensive strategies.

A growing body of literature has examined the links between narcissism and psychosocial impairments, particularly in the realm of interpersonal functioning. Using laboratory measures, Thomaes and colleagues (2008) demonstrated that those with high self-esteem and high levels of narcissism were likely to administer a loud ‘revenge’ noise-blast to an opponent after they had been shamed by that opponent in a computer game. This holds true in more systematic, daily approaches; using an ecological momentary assessment, Wright and colleagues (2017) found that when individuals high in narcissism perceive others as asserting themselves, they are more likely to respond with quarrelsome behavior. A study by Paulhus (1998) found that participants who self-enhanced were initially liked by other participants but became disliked as time progressed due to their obvious self-serving goals. Ogrodniczuk and colleagues (2009) examined interpersonal impairment for individuals with high, moderate, and low levels of narcissism. Results revealed that individuals with more narcissistic features were rated as more domineering and vindictive and were less likely to complete treatment. Roche and colleagues (2013) found that all forms of narcissism (pathological and otherwise) are associated with agentic interpersonal problems, but only pathological narcissism was also associated with communal interpersonal problems and distress. Work by Dickinson and Pincus (2003) examined differences in grandiosity and vulnerability with regard to interpersonal distress, finding that though those high in grandiosity may belittle others or devalue interacting partners in the face of threats to their self-esteem, only those high in vulnerability reported experiencing significant interpersonal distress. The fact that research has largely emphasized narcissism’s association with interpersonal dysfunction is unsurprising given that personality disorders broadly are specifically marked by interpersonal problems (American Psychological Association, 2013).

Though scant, some research has examined narcissism, or close correlates of narcissism (e.g., antagonism), and broader domains of functioning. For example, Ro and colleagues (2017), examined associations between facets of antagonism and different domains of functioning. Results revealed that antagonism is not solely related to poor interpersonal functioning, but rather poor functioning spans a range of domains, including well-being and daily functioning. Miller and colleagues (2007) found that impairment was the largest mediator between narcissism and distress, suggesting that poor outcomes in relationships, work, and social life, for example, result in a greater level of distress among narcissistic individuals. However, the strongest effects in this study emerged with regard to narcissism and causing pain and suffering to others. From this, the authors conclude that narcissism is a disorder that primarily causes dysfunction and distress in the interpersonal domain. Preliminary work by Ellison and colleagues (2013) and Pincus and colleagues (2009) examined how grandiosity and vulnerability affected outcomes like depression, violence, and suicidality among outpatients. However, each study examined only a small number of participants. Indeed, little research examining narcissism’s association with broad domains of functioning exists when compared with studies examining narcissism and interpersonal functioning

Broadly, the existing literature suggests that narcissism has associations with various functioning variables, and specifically interpersonal functioning. These associations appear to vary depending on whether capturing grandiose, vulnerable, or antagonistic aspects of narcissism. Links between narcissism and functioning are further complicated by the use of different measures across studies, which often have distinct operationalizations of the construct. In particular, measures such as the Narcissistic Personality Inventory (Raskin & Terry, 1988) have been shown to largely capture grandiose features (e.g., Pincus et al., 2009). On the other hand, measures designed to assess the DSM’s articulation of narcissism (e.g., Personality Diagnostic Questionnaire—4; Hyler, 1994) typically capture a blend of grandiose and vulnerable components. Although this comports with clinical manifestations of narcissism, measures based on the DSM criteria offer no replicable differentiation between grandiose and vulnerable features (Aslinger et al., 2018). Finally, the Pathological Narcissism Inventory (PNI; Pincus et al., 2009), which has subscales of grandiosity and vulnerability, was uniquely designed to capture pathological variants of narcissism as they manifest in clinical populations. Thus, as researchers seek to understand narcissism’s association with functioning, measurement selection is very important.

The Current Study

This study aims to shed light on the clinical manifestations of grandiosity and vulnerability and their associations with psychosocial dysfunction. The present study uses the PNI in a clinical sample, expanding on previous research by including pathological variants of both grandiosity and vulnerability to examine how each together and uniquely contribute to a broad range of functioning domains. Importantly, few studies have examined narcissism across broad domains of functioning when compared to studies examining interpersonal dysfunction. Fewer studies still have examined clinical levels of narcissism and associations between grandiosity, vulnerability, and an expanded set of functional outcomes. It was hypothesized that vulnerability, both from a univariate and multivariate perspective, would be associated with a broad range of poor functioning, whereas grandiosity would be more circumscribed in its associations with poor functioning domains. The PNI grandiosity subscale shares considerable variance with vulnerability (e.g., Miller et al., 2014; Edershile et al., in press). Thus, we hypothesize that only after accounting for the shared variance in vulnerability, will grandiosity exhibit negative associations with dysfunction. As an ancillary investigation, we additionally examined associations between the shared variance of grandiosity and vulnerability and the same functional outcomes. We hypothesized that these association would look much like those between vulnerability and functioning, given the saturation of maladaptivity in the PNI.

Method

Participants

Participants were recruited using flyers posted around mental health clinics across Western New York. To participate, participants had to be at least 18 years of age and had received psychiatric treatment within the past 2 years. The final sample included 628 participants (M age = 43.2; 63.5% female). Eighty percent of the individuals in the sample were currently in treatment, 10% within the last year, and 5% within the last two years. The measures of interest fell towards the end of a lengthy clinical interview and self-report protocol. Thus, at times participants were unable to complete the study procedures. 288 individuals (M age=36; SD=.69)1 completed the relevant measures and were included in the present study. All procedures were approved by the university’s Institutional Review Board. For other methods and procedures not related to the current study, please refer to Wright & Simms (2015).

Measures

The Pathological Narcissism Inventory(PNI; Pincus et al. 2009)

The PNI is a 52-item self-report measure developed to assess narcissistic grandiosity (PNI-G; Exploitativeness, Grandiose Fantasy, Self-sacrificing Self-Enhancement) and narcissistic vulnerability (PNI-V; Contingent Self-esteem, Hiding the Self, Entitlement Rage, Devaluing; Wright, Lukowitsky, Pincus, & Conroy, 2010). Items are scored on a 6-point Likert scale (0, not at all; 5, very much like me). The internal consistency for PNI-G was α = .87 and for PNI-G α = .95. PNI-G and PNI-V and vulnerability correlated at r = .61.

World Health Organization Disability Assessment Schedule 2.0 (WHODAS-II; World Health Organization, 2010)

The WHODAS-II is a 36-item interview that assesses functioning in the domains of communication, mobility, self-care, getting along, life activities, and participation in society over the last 30 days. Higher global and domain scores reflect poorer functioning. Inter-rater reliability for these scores (measured by kappa) ranged from .67 to .87.

The Multidimensional Dysfunction Aggregate (MDA; Wright et al., 2015)

The MDA is a brief (5-item) measure of psychosocial functioning with questions that target well-being, self-control, interpersonal functioning, everyday life tasks, and occupational functioning. Participants responded with the extent to which they experienced difficulty in these areas on a 100-point scale ranging from Not at all to Very much, with higher scores indicating greater difficulty. Internal consistency (alpha) of the total score was .73.

Inventory of Interpersonal Problems (IIP; Soldz, Budman, Demby, & Merry, 1995)

The mean of the 32 items of the IIP was used to indicate overall level of interpersonal problems and associated distress. Internal consistency was high (α = .93).

Satisfaction with Life Scale (SWLS; Diener, Emmons, Larsen, & Griffin, 1985).

The SWLS is a 5-item self-report measure that assesses overall well-being and satisfaction with life (α = .90). Higher scores on this measure indicate greater satisfaction with life.

Suicidality

Past month severity of suicidal ideation was assessed via clinical interview. Responses were coded as an ordinal scale (0–5), where 5 (1% of participants) indicated that the individual attempted suicide, 4 (5.1% of participants) indicated that the individual had a plan, 3 (14.1% of participants) indicated thoughts of suicide, 2 (.7% of participants) indicated desire to harm self, 1 (6.1% of participants) thoughts that they would be better off dead, and 0 (73.1% of participants) indicating no suicidal thoughts, plan or action.

Results

For all outcomes, we ran univariate and multivariable regressions with PNI-G and PNI-V as predictors. Correlations among all outcome variables can be found in Supplementary Table 1. Additionally, for results examining associations between the shared variance of PNI-G and PNIV and functioning outcomes, please see Supplementary Table 2.

Results of the univariate linear regression can be found in Table 1. PNI-V was a significant predictor of poorer functioning across all outcome measures. In the univariate models with PNI-G significant associations were found only for the Inventory of Interpersonal Problems, three subscales of the World Health Organization Disability Assessment-II (including Cognition, Getting Along with Others, and Participation in Society), and Impulse and Relationships of the Multidimensional Dysfunction Aggregate.

Table 1.

Summary of Simple Regression Analyses for Variables Predicting Domains of Functioning in Grandiosity and Vulnerability

Outcome Grandiosity Vulnerability

B p β 95% CI B p β 95% CI
SWLS 0.26 0.601 0.03 [−.73, 1.26] −2.53 <.001 −0.32 [−3.44,−1.62]
IIP 6.19 <.001 0.28 [3.54, 8.85] 13.95 <.001 0.63 [11.85, 16.04]
WHODAS-II
Cognition 3.43 0.020 0.15 [0.55,6.31] 8.98 <.001 0.39 [6.36, 11.61]
Mobility −0.72 0.718 −0.02 [−4.61,3.18] 4.58 0.017 0.14 [0.83, 8.33]
Self Care −0.5 0.582 −0.04 [−2.31, 1.30] 2.15 0.015 0.15 [0.42, 3.89]
Getting Along with Others 5.48 0.003 0.19 [1.89,9.07] 13.16 <.001 0.45 [9.97, 16.36]
Work 2.78 0.102 0.10 [−0.56,6.11] 7.26 <.001 0.27 [4.12, 10.41]
Participation in Society 4.75 0.015 0.16 [0.91, 8.59) 12.74 <.001 0.41 [9.27, 16.20]
Full Score 2.26 0.068 0.12 [−0.17,4.68] 7.74 <.001 0.39 [5.54, 9.93]
MBA
Dissatisfaction 1.81 0.922 0.01 [−34.72, 38.35] 81.77 <.001 0.28 [47.82, 115.63]
Mobility 16.95 0.442 0.05 [−26.58, 60.48] 68 <.001 0.20 [26.99, 108.99]
Impulse 53.42 0.008 0.17 [14.28,92.56] 120.84 <.001 0.38 [85.47, 156.22]
Relationships 49.29 0.015 0.15 [9.81,88.78] 116.87 <.001 0.36 [80.69, 153.05]
Work 24.94 0.262 0.07 [−18.76,68.65] 98.28 <.001 0.28 [57.52, 139.04]
Full Score 29.32 0.045 0.13 [0.59, 58.06] 99.27 <.001 0.43 [73.89, 124.66]
Suicidality .01 .938 .01 [−.17. .19] .33 <.001 .23 [.17, .49]
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Note. N=288. CI=Confidence Interval. SWLS=Satisfaction with Life Scale. IIP=Inventory of Interpersonal Problems. WHODAS-II = World Health Organization Disability Assessment Schedule 2.0. MDA = The Multidimensional Dysfunction Aggregate.

Results of the multivariate regressions are in Table 2. Accounting for the shared variance in PNI-G and PNI-V, PNI-V continued to be significantly associated with poorer functioning in all domains, whereas PNI-G yielded associations with better functioning across many domains. This included significant positive associations with Satisfaction with Life Scale, significant negative associations with the Inventory of Interpersonal Problems, all subdomains of the World Health Organization Disability Assessment-II except Cognition and Work, and Dissatisfaction and Work of the Multidimensional Dysfunction Aggregate. No significant associations between PNI-G and poorer functioning remained once accounting for shared variance with PNI-V.

Table 2.

Summary of Multiple Regression Analyses for Variables Predicting Domains of Functioning in the Interaction of Grandiosity and Vulnerability

Outcome Grandiosity Vulnerability

B p β 95% CI B p β 95% CI
SWLS 2.99 <.001 0.37 [1.79,4.075] −4.24 <.001 −0.53 [−5.34,−3.14]
IIP −4.08 0.003 −0.19 [−6.78,−1.38] 16.32 <.001 0.74 [13.72, 18.92]
WHODAS
Cognition −3.31 0.053 −0.14 [−6.674, 0.05] 10.92 <.001 0.47 [7.65, 14.19]
Mobility −5.54 0.023 −0.17 [−10.33, −0.76] 7.82 0.011 0.24 [3.17, 12.47]
Self Care −2.86 0.011 −0.20 [−5.07, −0.66] 3.82 0.001 0.27 [1.67,5.97]
Getting Along with Others −4.14 0.047 −0.14 [−8.22, −0.06] 15.58 <.001 0.54 [11.61, 19.55]
Work −2.67 0.195 −0.10 [−6.71, 1.37] 8.82 <.001 0.33 [4.89, 12.75]
Participation in Society −4.87 0.031 −0.16 [−9.30, 0.44] 15.58 <.001 0.51 [11.27, 19.88]
Full Score −3.94 0.006 −0.20 [−6.73,−1.15] 10.04 <.001 0.51 [7.33, 12.75]
MBA
Dissatisfaction −76.49 0.001 −0.26 [−119.65,33.32] 125.85 <.001 0.42 [84.29,167.4]
Mobility −38.96 0.150 −0.11 [−92.06, 14.14] 90.16 0.001 0.26 [39.29,141.0]
Impulse −33.9 0.147 −0.11 [−79.77, 11.97] 140.31 <.001 0.44 [96.25,184.3]
Relationships −36.86 0.122 −0.11 [−83.59, 9.88] 138.36 <.001 0.42 [93.14,183.5]
Work −57.51 0.032 −0.16 [−110.12,4.89] 131.86 <.001 0.38 [81.02,182.7]
Full Score −51.2 0.002 −0.22 [−83.67, 18.74] 129.02 <.001 0.56 [97.70,160.3]
Suicidality −.34 .002 −.22 [−.56, −.13] .52 <.001 .37 [.32, .72]
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Note. N=288. CI=Confidence Interval. SWLS=Satisfaction with Life Scale. IIP=Inventory of Interpersonal Problems. WHODAS-II = World Health Organization Disability Assessment Schedule 2.0. MDA = The Multidimensional Dysfunction Aggregate.

Discussion

The present study aimed to clarify the associations between grandiosity and vulnerability and different domains of psychosocial functioning. Prior research suggested that narcissism is associated with poorer functioning. However, much of this work either only examined interpersonal functioning or failed to gain a complete picture of how grandiosity and vulnerability individually and concurrently contribute to broad domains of functioning. Unique contributions of grandiosity and vulnerability have not previously been examined in a clinical sample. To address this limitation, we examined the concurrent, shared, and unique contributions of grandiosity and vulnerability to psychosocial functioning, using the PNI, which was designed to assesses these subdomains as they manifest in clinical settings.

We hypothesized that vulnerability would be associated with poor functioning across a broad range of domains whereas grandiosity would have narrower associations. When entered as predictors in separate models and in line with predictions, vulnerability was globally associated with dysfunction, whereas grandiosity’s associations were more circumscribed, yielding associations with scales that primarily captured poor interpersonal functioning. However, previous research has suggested that the PNI’s grandiosity scale is saturated with vulnerability (e.g., Miller et al., 2016; Wright et al., 2013), such that it may be the variance shared with vulnerability that contributes to dysfunction for individuals high in grandiosity.

Edershile and colleagues (in press) demonstrated that taking a multivariable approach, as done in the current study, clarifies the association with grandiosity. Indeed, this is the case in the present study, such that whereas vulnerability continued to be associated with poorer functioning in every domain, grandiosity was unassociated with poor functioning across a broad range of outcomes and positively with better functioning in some areas, such as satisfaction with life. Indeed, Rathvon and Holstrom (1996) suggest that grandiosity is negatively associated with depression and anxiety in social situations and it is often argued that narcissism has adaptive components (e.g., Pincus & Lukowitsky, 2010; Stone, 1998). These are found when using pure measures of grandiosity not designed to capture pathological manifestations of narcissism. The strong relation we found between vulnerability and dissatisfaction highlights vulnerability’s established relationship to depressive temperaments (Ellison et al., 2013; Rathvon & Holmstrom, 1996; Cooper & Ronningstam, 1992) and potential suicide risk (Ansell et al., 2015). Our results expand on previous research, however, to suggest that pathological variants of narcissism holistically associate with broad dysfunction. Pathological grandiosity and it’s overlapping features with vulnerability tend to associate with poor interpersonal function, specifically.

Given the striking difference in univariate and multivariable results, it is important to select appropriate analytic strategies and measures when addressing the intricacies of narcissism. Here, the PNI was the measure of choice given that this was a clinical sample and the PNI was developed specifically for clinical manifestations of narcissism. We view the saturation of maladaptively not as a limitation of the measure, as some have suggested (e.g., Miller et la., 2014; Miller et al., 2016), but rather a feature of what the measure was designed to do—detect clinical manifestations of pathological narcissism. Nonetheless, even in such a sample, pure grandiosity appears to be unassociated with dysfunction, whereas the shared variance of grandiosity and vulnerability, and the unique components of vulnerability are associated with dysfunction in a broad range of areas.

Our results have important implications for how we think about narcissism and the relation between grandiosity and vulnerability. Though pathological narcissism is thought to be an impairing disorder with detrimental outcomes (Ansell et al., 2015; Ellison et al., 2013; Pincus et al., 2009), our results suggest the picture is not that simple. Grandiosity, after removing variance that is shared with vulnerability, may confer several advantages that protect against dysfunction, even in a clinical population. It is the domain of vulnerability, as well as the shared characteristics of grandiosity and vulnerability, however, that largely drive dysfunction. Indeed, narcissistic individuals do not tend to seek treatment until they are in a vulnerable state, but have been clinically theorized to fluctuate between the two (Pincus & Lukowitsky, 2010; Pincus et al., 2009; Pincus, Cain, & Wright., 2014). Our results further suggest that the motivations for seeking treatment in narcissistically vulnerable individuals may be due to overtly poor functioning in a wide range of areas. Grandiose individuals, on the other hand, may notice little impairment in functioning and may even benefit from feeling successful in many different areas of functioning, though objective measures of functioning were not addressed in the present study.

This study had several limitations. First, this study used self-report measures, which in addition to established issues of shared method variance, may compromise study generalizability. Due to this, it may be that self-report measures of domains of functioning more accurately capture perceived functioning. As previous research suggests, this may impact variants of narcissism differently; individuals with many narcissistic features may be less aware of their surroundings and their impact on other people (e.g., Paulhus & John, 1998), which is most likely true for those with grandiose narcissism. This is not to say they are generally doing well, however, as absence of distress does not equal absence of dysfunction. For those with grandiose narcissism, rather, their pathology may lie more in the damage they do to others (Miller et al., 2017). Further, work by Sleep, Selbom, Campbell, and Miller, (2016) found that vulnerable narcissism is negatively related to under-reporting psychology, suggesting there may, in fact, be a bias to report more distress. As such, our results may be an indication of perceived distress rather than reflect objective issues within the individual’s life. Nonetheless, perceived functioning and distress have more meaningful implications when thinking about motivations for seeking treatment, for example, and should not be disregarded. Future studies may wish to incorporate other assessment tools, for example passive sensing or informant report.

There has been a debate in the literature regarding the extent to which grandiose and vulnerable narcissism are related, with some finding evidence that the nomological networks of the two are largely independent constructs (Miller et al., 2011). Moreover, some have argued that the PNI captures a specific type of patient with pathological narcissism. This patient may have grandiose features but likely possesses much more vulnerability than “typical” grandiose narcissists (Miller et al., 2014). To this end, future research may wish to include additional measures of narcissism, such as the Five Factor Narcissism Inventory (FFNI; Glover et al., 2012), to examine how results are similar or different to those in the present manuscript.

The current study examined the unique effects of grandiosity and vulnerability on different domains of functioning. This study shed light on the complexities of pathological narcissism, revealing that vulnerability is clearly predictive of poor functioning whereas grandiosity may serve as a protective factor but only when accounting for level of overall dysfunction. To gain an understanding of the mechanisms driving narcissism, studies that examine both the combined and unique effects of grandiosity and vulnerability will be important. Understanding the core deficits in pathological narcissism and the breadth of dysfunction will help improve both treatment and understanding of narcissism.

Supplementary Material

Supplemental Material

Acknowledgments

First authorship is shared between Samantha C. Dashineau and Elizabeth A. Edershile. This research was supported by grants from the National Institute of Mental Health (L30 MH101760, Wright; R01 MH080086, Simms). The opinions expressed are solely those of the authors and not those of the funding source.

Footnotes

1

To evaluate patterns of missingness, we performed two Analyses of Variance (ANOVAs) to address if there were any differences in age or sex between those who were included in analyses and those that were not. ANOVA results indicated that there were no differences in gender for those that were included and those that were not (F (2, 625) =2.123, p =.120). Conversely, there were significant differences in age between those included and those not (F (54, 573) =2.195, p<.001). This is likely the case because individuals who were older moved slower through the study procedures and, thus, did not make it to the end of the protocol. Additionally, ANOVAs were performed across all 10 PDs to examine if there were differences between those included in analyses and those not. Significant differences emerged for schizoid PD, F(7,611) =2.909, p=.005, such that individuals who did not complete the PNI tended to have more schizoid PD features (included mean = 2.57; excluded mean = 3.09).

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