Narcissism Key: from healthy to pathological

Without a working framework, my blog might be confusing because I write about narcissism as a normal personality trait while writing about pathological narcissism as a clinical diagnosis. I also write about my struggles with unhealthy narcissism which should not be equated to a personality disorder. (Unless you hate me and then you can accuse me of having a NPD which a few people have surmised. Hint: none of them was my therapist or my kids, the latter being more credible...)

So what does narcissism mean to you? Is narcissism a concept in psychoanalytic theory, a trait, a process, a personality variable, a disorder? Narcissism confounds most people and yours truly is frequently confused which is why narcissism remains endlessly fascinating and frustrating. Social psychologists disagree with clinical psychologists who disagree among themselves: is narcissism a part of normal psychological development as Kohut theorized; or is narcissism as Otto Kernberg suggests: "the libidinal investment in a pathological self-structure,” i.e.: the inability to love others.

To most people, narcissism is an air of superiority, a lack of empathy, obliviousness to the impact their behavior has on others. Narcissism is blaming, shaming, and defaming anyone who dares offend or criticize. To many people, narcissism means "never having to say you're sorry" because everyone should want what's best for the narcissist, even if it isn't best for themselves. To most of us, narcissism is Gross Hypocrisy--saying one thing while doing another; claiming to be better than we actually are (okay social psychologists, it's true...everyone self-enhances but not to the point of absurdity-and-nonsense).

Descriptions of narcissism in the clinical/pathological literature also describe the normal narcissism of nonclinical/normal populations. Every human being needs admiration and attention, has an occasional lack of empathy, a desire for success and love. Every human being likes having power and control and might be a tad grandiose and self-important, once-in-a-while. Two other traits causing relational problems for all of us? Using others to meet our needs; i.e.: Entitlement and Exploitation. It's frustrating knowing where to peg someone on the narcissism spectrum, including where we might find ourselves. Now some people might argue that measuring someone's narcissism is an exercise in judgmentalism. That may be true in some cases but it's crucial for understanding how pathological someone's narcissism might be, especially when deciding to end the relationship or stay. We need to be as clear-eyed as possible. An everyday "normal narcissist" will hurt our feelings and push our boundaries beyond comfort levels; a malignant narcissist will push us "over the edge". Metaphorically and literally, my friends.

As you can see on the graph, normal narcissism doesn't necessarily mean healthy and quite honestly, the vast majority of human beings fall short of the ideal. Modifying unhealthy narcissism as soon as we 'catch ourselves in the act' allows us to live to our fullest potential. So instead of denying we have issues, let's cop to our crimes-and-misdemeanors and get to work on being human: interconnected, conscientious, compassionate, communal, and kind.

As a disclaimer: my graph is intended for self-helpers. I have referenced social and clinical psychologists most readers will recognize, including credible resources for each position on the graph. Numerous quotes are incorporated in my article because I'm not a psychologist and have zero-absolutely-no interest promoting myself as such. This graph is a working framework of my layperson understanding of social, clinical, normal, developmental and abnormal antisocial white flag narcissism.  Be sure to check out my bibliography and remember, if it's pink, it's a link.

Since this article is rather long, peg yourself (or others) on the graph and scroll down to the relevant information. I've added academic research to each section and the bibliography is hyper-linked to make it super-easy to find articles. If a link is broken, let me know. Thanks!

Normal Narcissism 

"In a broad sense, narcissism refers to feelings and attitudes toward one’s own self and to normal development and self-regulation. It is the core of normal healthy self-esteem, affects, and relationships. In psychoanalytic terms, normal narcissism is defined as a positive investment in a normally functioning self-structure.” ~(pg. 31) Elsa Ronningstam 

“The narcissistic self is perhaps most usefully conceptualized as a self-regulatory system: it is an interactive group of traits, abilities, beliefs, strategies, behavior, and emotions that mutually predict and reinforce each other, a strategy for regulating self-esteem via grandiosity.” (Campbell and Foster) 

"Normal narcissism is characterized by self-centeredness, self-aggrandizement, and a manipulative interpersonal orientation." ~Pinsky, Narcissism and Celebrity

"Narcissism is a sense of personal grandiosity and a preoccupation with promoting the self and its desires." ~Tamborsku and Brown

 "Narcissism is characterized first and foremost by a positive and inflated view of the self, especially on agentic traits (e.g., power, importance, physical attractiveness). In a sense, narcissism can be conceptualized as a self-regulating system, where self-esteem and enhancement are sought through a variety of social means, but with little regard for the consequences borne by others." ~Twenge, Egos Inflating Over Time 

Pulling this graph together required a more complex view of narcissism than the categorical: “yup, you got it”, “nope, you don’t" because the real truth is that we've all got it, some worse than others. Normal narcissism is the yucky narcissism staring back in the mirror when our inner-brat holds the outer-adult hostage. This unhealthy, age-inappropriate narcissism frustrates intimate relationships, especially when partners aren't in sync, leapfrogging their way to old age. (Erikson) Most people are commited to lifelong pair bonding as a value. But remember: the more value we place on commitment, the greater the impetus for personal change because we want to keep the relationship together. Relinquishing childish behaviors to improve the relationship, generates psychological growth and self-development. Unhealthy narcissism stagnates relationships with others and hinders our personal “joie de vivre”.

Recovery Work

Kohut’s self-psychology describes the narcissism familiar to people in “recovery work” since unhealthy narcissism is a predictable problem if we were raised in a dysfunctional family. And most of us were. Charles Whitfield suggested a mere 0-5% of families were healthy; 25% severely dysfunctional (1991). Recovery groups such as 12-step are phenomenally validating and educative as to what is normal maturation and what's not. Church groups, mutually compassionate friendships and even sibling relationships facilitate maturation and recovery. Codependency groups can be life-changing. Self-help books “kick-start” or augment a natural growth process. Healthier age-appropriate narcissism fosters healthier self-esteem leading to healthier relationships and a more meaningful life. I believe that.

The developmental approach towards healthy narcissism encourages people who were raised in dysfunctional families, proposing they can improve their lives IF: they are self-aware; are willing to do the work; can tolerate difficult emotions; have the capacity for insight; care about the effect their behavior has on others; have the ability to keep commitments; can face imperfection, failure and criticism; and have the ability and willingness to accept and mourn inevitable losses. And last but not least: are motivated to change.

“A person’s inner life is not a given, it is a construction. My life is ultimately my own creation; narcissism smothers that creation, does not allow it, and prevents energy from being available to make it possible.” ~Neville Symington  

See my post: Testing Normal and Yucky Narcissism 

Clinical Narcissism

“When the wish to be loved transforms into the need to be admired.” ~Frank Yeomans

Putting the Narcissistic Personality Disorder at the far right of the graph might be misleading but rest assured, without specific childhood conditions (and a possible genetic predisposition), you won’t turn into a malignant narcissist even if you're painfully focused on yourself. Readers often write that they're more self-absorbed than ever, shamefully concerned about being selfish, self-centered, bouncing between unstable highs and lows. Well, let me be honest. When my self-esteem plummeted to a frightening low, I bounced between Recovery-Hero-Extraordinaire and Complete-n-Total-Failure. The yo-yo-ing eventually settled down and thank god the people who loved me were able to deal with the whiplash. What I experienced was being narcissist-ick (emphasis on the "ick"). I knew something was wrong and my behavior was upsetting other people and I was motivated to change. That's not clinical narcissism.

"Being highly narcissistic or a narcissist, is not the same as having a diagnosed psychiatric disorder or a pathological level of narcissism." ~(pg.22) Twenge

Pathological narcissism (clinical narcissism) must meet five of nine criteria listed in the DSM.  A person with a NPD will suffer some form of impairment. Pathological narcissism is indicated by inter-personally destructive relationships and an intra-personally dysfunctional relationship with the self. NPD is diagnosed by a person's inability to live to their fullest potential, a failure to thrive at work and at home. At a certain point (which may not occur until midlife) it becomes only too obvious that something is wrong with that person. In my view, their narcissism failed to sustain an undeveloped grandiose self. This is not unhealthy narcissism, it's pathological.

At the root of the pathological narcissist is a grandiose self, compensating for low self-esteem by projecting a self-confident image. Their competency fools other people and the narcissist, too. Until it doesn't when their illusion of grandiosity is insupportable. While the extraordinary narcissist manages extreme stress without breaking a sweat, or breaking down, I can tell you from personal experience that pathological narcissists do. They become anxious and insecure, fearful they've promoted themselves beyond their ability to perform. The resultant fear of humiliation for having failed impossible expectations (i.e.: unlimited success and brilliance), can be overwhelming, the hound of failure and depression nipping at their heels. Treating pathological narcissism requires intensive therapeutic intervention, yet grandiosity fools them into believing they can “fix” themselves. They cannot. Even in the face of incontrovertible evidence, narcissists don’t believe anything is wrong with them. It's everyone else that's the problem. Narcissism is self-deceptive.

Such breathtaking defiance isn't the case for everyone with a NPD, however. A study by Russ, Shedler, Bradley and Weston verifies what many of us have witnessed: pathological narcissists suffer “underlying pain, vulnerability, inadequacy.” They also suffer low self-esteem. While psychologists continue studying the high self-esteem of "normal" narcissists, clinical narcissism is distinguished by low self-esteem.

Clinical narcissism is distinguished by low self-esteem.

It's the normal narcissists who believe they’re special, superior, and extraordinary. “There is no need to worry about the self-esteem of the [normal] narcissist," writes Dr. Allan Schwartz, "they have an over-abundance of it.”

Self-Help vs. Therapy

People with a narcissistic personality disorder cannot mature through self-help work alone, an important distinction between normal and clinical narcissism. Through corrective experiences and self-help, unhealthy narcissism can mature; without therapeutic support, pathological narcissism worsens. It does not get better. Unfortunately, people with a narcissistic personality disorder assume they’re walking the same path as the rest of us (only faster and better, ha!).  Dr. Schwartz writes, "[NPD] causes people to misunderstand what is really going on with the individual. For example, some one like this will seem to be arrogant and filled with self-confidence. However, just beneath this shallow surface lies a person who feels a deep sense of shame and humiliation and low self-esteem. That is why they are so easily hurt in the face of criticism."

In my view, each of us falls somewhere on the narcissistic continuum. Wherever we might peg ourselves on this graph, persistent effort toward healthier narcissism is a reasonable and worthwhile goal.

See my post: Corrective Life Events: Can the Narcissist Change?

“The ultimate blow to narcissism is the fact of our own death; coming to terms with death is a mark of maturity and wisdom. For Kohut, narcissism, successfully negotiated, leads to the capacity to accept mortality, to see oneself as one is without over-or-underestimation, to develop a sense of creativity and humour and to trust one’s intuition and empathy. The paradox of this process is that narcissism needs to be healthily established before it can be given up.”(pg. 43) Jeremy Holmes 

Healthy----Stable----Destructive----Pathological 

“The undoubted abuses of pernicious narcissism should not blind us to the necessity of healthy narcissism; it has been suggested that we learn to think in terms of a narcissistic continuum, with stable narcissism closest to healthy narcissism and the destructive narcissistic pattern closest to pathological narcissism.” Wikipedia link 

Healthy Narcissism 

“Kohut (1977) considers healthy narcissism in adults to be characterized by creativity, empathy, a sense of humor, awareness of finiteness and wisdom...Transformed narcissism, as used this way, appears to mean narcissism appropriate to age and phase of development that is expressed and experienced as a healthy appreciation and enjoyment of our activities, a sense of direction, a system of values that guides us and a helpful feeling of disappointment that incorporates some anger and shame when we fail to live up to our expectations of ourselves.” ~(pg.1-2) Brown, DNP

“Healthy narcissism plays a crucial role in the human capacity to manage challenges, successes and changes; to overcome defeats, illnesses, trauma, and losses; to love and be productive and creative; and to experience happiness, satisfaction, and acceptance of the course of one’s life.”~Ronningstam

“People with healthy levels of narcissism are able to step outside their own perspective long enough to assess how their behavior may be affecting others around them. This ability to avoid becoming stuck in narcissistic mode, and to consider the impact of your actions on the feelings of others, is one of the key distinctions between healthy and extreme levels of narcissism.” (pg. 90) Pinsky

“Healthy narcissism contains the seeds of assertiveness and self-respect.” ~Wendy T. Behary

Mature individuation
Communal concerns
Balance of self  and other
A grateful “Joie de Vivre”
Realistic self-evaluation
Appropriate Self-regard
A fully-developed conscience
Self and object constancy
Empathy, altruism, and compassion for others
Respect for the rights and feelings of others
Entitlement without infringing on the rights of others
A balance of agentic and communal traits
Reciprocal mutuality: the ability to give and take
Ability to satisfy one’s desires
Ability to grieve one's losses
Resilient self-esteem to life's "ups and downs"
Ability to create and sustain intimate relationships
Ability to live in accord with one’s moral values and principles
Capacities to self-reflect, acknowledge problems, and take responsibility (Payson)
Enlightened self-interest without neglecting needs and hopes for advancement (Stone)

See my post: Descriptions of Healthy Narcissism

See my post: Healthy Narcissism and Self-Admiration

Stable Narcissism

“Stable Narcissism is a concept proposed by Kohut (1977) to describe less than total expected or appropriate narcissism. That is, the individual has primarily age-appropriate narcissism but there are areas where he or she has not fully developed. For example, some variations of conceit, selfishness and vanity are considered by Kohut to be representative of stable narcissism. The individual functions well, has satisfying relationships but could also be described as smug, selfish on occasion, and is very concerned about the image he or she projects.” ~(pg. 17-18) Brown, DNP 

"Shame is the feeling that lurks beneath all unhealthy narcissism, and the inability to process shame in healthy ways---to face it, neutralize it, and move on as healthier individuals do---leads to the characteristic postures, attitudes, and behaviors of narcissists." (pg. 6) Hotchkiss

Extraordinary Narcissism (Ronningstam)

Heightened self-regard
Heightened entitlement
Heightened exhibitionism
Tremendous self-confidence and self-worth
Exaggerated sense of indestructibility
Unusual risk-taking and decision-making
Unusual sense of responsibility and commitment
Charismatic, dominant, competitive

Productive Narcissism (Maccoby)

"A narcissist may be either productive or unproductive. The difference is that the most productive narcissists, the ones who do change our world, have the charisma and drive to convince others to buy in to their vision or embrace a common purpose. They communicate a sense of meaning that inspires others to follow them, whereas the unproductive types retreat into their own world and blame others for their isolation." ~Michael Maccoby link

See my post: Extraordinary, Productive and Exaggerated Narcissism  

Codependency 

“The person with unhealthy narcissism is acting the way our parents probably meant when they told us not to be “selfish.” Yet what many of our parents didn't teach us was a healthy self-caring”. ~(pg. 95) Whitfield

“Children of the self-absorbed have to work particularly hard throughout their lives to attain [a healthy] level of development, as they were not allowed to complete the expected tasks at an earlier age. If you had a parent with a destructive narcissistic pattern, you may have areas of underdeveloped narcissism that need attention." ~Nina Brown link

Age-inappropriate narcissism causes enough distress to threaten important relationships which can lead to changed behavior, which then leads to  taking more responsibility for ourselves, not less. That means ‘growing up’ which usually means letting go of childish ways even if'n we don't wanna. Wherever you are right now is the perfect place to re-parent yourself, caretaking any needs that were not honored and met by a narcissistic partner or parent. Learned behavior can be unlearned.

Signs of codependency:

People-pleasing
Poor boundaries
Reactivity
Caretaking
Control
Dysfunctional communication
Obsessions
Dependency
Denial
Problems with intimacy
Painful emotions (Lancer)
Pathological Altruism (Oakley)

I have reservations about the corollary codependency increasingly preached in narcissism groups. Certainly, codependency groups taught healthy principles for keeping the focus on myself: "How was I behaving? Was I causing, controlling, contributing to the mess?" Even so, defining everyone in a narcissistic relationship (or child of a narcissist) as a codependent is a bit ridiculous, especially if they function well in other areas of their lives. There are other ways to describe what happens in the narcissistic relationship, such as: cognitive dissonance, trauma bonds, the fantasy bond, intermittent reinforcement; and depending on the abuse: the Stockholm Syndrome, grief work and ptsd-trauma recovery (See Sandra L. Brown). Examining those relational dynamics keeps the focus on the perpetrator. Another important consideration is the situation, cultural norms, gender-divided roles, religious beliefs, etc. Unlike the typical "it takes two" dysfunctional relationship between EQUALS, narcissists deliberately and intentionally dominate family members to secure control, superiority and power over them. Nonetheless, Beattie, Bradshaw and Whitfield's observations about dysfunctional systems and codependency are illuminating and empowering albeit limited in explaining other determinants.

See my post: Is Lassie Co-dependent?
See my post: What Is It About Mary?

Co-Narcissism (Rappoport)

“People who behave co-narcissistically share the following traits: they tend to have low self-esteem, work hard to please others, defer to others’ opinions, focus on others’ world views and are unaware of their own orientations, are often depressed or anxious, find it hard to know how they think and feel about a subject, doubt the validity of their own views and opinions (especially when these conflict with others’ views), and take the blame for interpersonal problems.” ~ (pg. 2) Rappoport

Once again, depending on the degree of narcissism in your family-of-origin, you may or may not agree with Dr. Rappoport's conclusions. Because his article is based on his clientele, he isn't including people who grew up in narcissistic families yet found ways to mature/recover without subscribing to therapy. Some people want professional guidance; some don't. You can determine for yourself if the relationships you've created as an adult are healthy. Most people have at least a few things they'd like to change even if their family-of-origin was epitome of psychological health and development.

Signs of co-narcissism:

An undeveloped sense of self
Addictive compulsions
Lack of boundaries
Insecure, fragile sense of self
Codependency traits
Exists to fulfill dreams and expectations of parent  (Zomerland)

Even though my intuition placed codependency and co-narcissism as stable, unhealthy narcissism, I think both states can move towards destructive narcissism. Either concept is fluid enough to warrant a dimensional position on the continuum. Codependency might be pathological, such as the Dependent Personality Disorder. Covert narcissism (NPD) might be a manifestation of "pathological codependency", I really can't say for sure where the line might be between unhealthy codependency and a personality disorder. As I experienced in 12-step, some people got better within a few weeks, just having social support and a little self-help cognitive therapy. Other people had faithfully attended 12-step for years, still caught in the narcissistic web of endless chaos and misery.

See my post: Unbelieving the Unbelievable
See my post: Corrective life Events: Can the Narcissist Change?

Destructive Narcissism

“Destructive narcissism describes an individual who has some characteristics associated with pathological narcissism but may not be fully described or diagnosed as such. The individual has attitudes or behaves in ways that are destructive to self and others. He produces frustration in almost everyone who has to interact with him or her, devalues others, lacks empathy...As with the pathological narcissist, the DNP is best known by reactions produced in others from interactions with this person.” ~(pg.18) Brown, DNP

Destructive Narcissistic Pattern (Brown)

Signs of destructive narcissism:

Shallow emotions
Lack of empathy
Indifference to others
Strong admiration and attention needs
A strong self-focus and self-absorption
Unresponsive to others needs or concerns; manipulative
Grandiose, arrogant and contemptuous
Consideration of oneself as unique and special
An inability to relate to others in a meaningful way
An inability to grasp one's core self

See my post: NPD and DNP
See my post: Destructive Narcissistic Pattern

Unproductive Narcissism (Maccoby)

"The danger is that narcissism can turn unproductive when, lacking self-knowledge and restraining anchors, narcissists become unrealistic dreamers. They nurture grand schemes and harbor the illusion that only circumstances or enemies block their success. This tendency towards grandiosity and distrust is the Achilles' heel of narcissism. Because of it, even brilliant narcissists can come under suspicion for self-involvement, unpredictability and---in extreme cases---paranoia. It is easy to see why narcissistic leadership doesn't always mean successful leadership." ~Michael Maccoby link 

See my post: Extraordinary, Productive and Exaggerated Narcissism 

Healthy vs. Destructive Narcissistic Managers 
wikipedia ink

Characteristic	Healthy narcissism	Destructive narcissism
Self-confidence	High outward self-confidence in line with reality	Grandiose
Desire for power, wealth and admiration	May enjoy power	Pursues power at all costs, lacks normal inhibitions in its pursuit
Relationships	Real concern for others and their ideas; does not exploit or devalue others	Concerns limited to expressing socially appropriate response when convenient; devalues and exploits others without remorse
Ability to follow a consistent path	Has values; follows through on plans	Lacks values; easily bored; often changes course
Foundation	Healthy childhood with support for self-esteem and appropriate limits on behaviour towards others	Traumatic childhood undercutting true sense of self-esteem and/or learning that he/she doesn't need to be considerate of others

*     *     *     *     *     *

“Narcissists are too busy proving their worth---or, more properly, denying their worthlessness to feel the love, appreciation and joy of human connectedness which their good works could potentially stimulate in themselves and others. These people are not character disordered. They are people tortured by narcissistic injury and crippled by developmental arrests in functioning which rob them of the richness of life they deserve. They are good people, contributing people who are hurting---and often very badly. They are living and suffering the narcissistic style.” ~Steven Johnson (pg. 3) 

*     *     *     *     *     *

"To only stress their suffering could lead to sentimentality and collusion." ~Linda Martin 

*     *     *     *     *     *

Pathological Narcissism

"People with NPD have difficulty maintaining relationships, are more likely to have mood disturbances, gravitate towards high drama, and have a much higher likelihood of using drugs and alcohol to excess." (pg. 14) Pinsky

“Patients with narcissistic behavior disorders loudly proclaim their sense of grandiose entitlement along with their expectation that others acknowledge and defer to it. Such character pathology is to be distinguished from narcissistic personality disorders, in which the behavioral picture is dominated by feelings of emptiness, a lack of vitality, and a tendency toward depression.” ~Arthur Malin, pdf link 

“Pathological narcissism spans a spectrum from failing to give others credit for their contributions to outright plagiarism or stealing of other’s ideas. Normal to pathological forms of competitiveness show themselves in innumerable areas of human activity.” ~(pg. 17) Stone

See my post: Blogduggery: This is not okay, even IF you're in Recovery

Personality disorders

"Personality disorders are associated with ways of thinking and feeling about oneself and others that significantly and adversely affect how an individual functions in many aspects of life. They fall within 10 distinct types: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder."~DSM5 factsheet

“Diagnostic overlap cuts across all three clusters in the DSM, specifically Cluster B co-morbidity." (pg. 28)  Silverstein 

Description of Clusters A, B and C 

Cluster B disorders

"Despite the low numbers of individuals who are diagnosed with narcissistic personality disorders, there has been an obvious increase in narcissistic and other Cluster B styles of behavior." (pg. 9) Pinsky

AntiSocial: a pervasive disregard for the law and the rights of others. 

Borderline: extreme "black and white" thinking, instability in relationships, self-image, identity and behavior often leading to self-harm and impulsivity.

Histrionic: pervasive attention-seeking behavior including inappropriately seductive behavior and shallow or exaggerated emotions. 

Narcissistic: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy

See my post: One of These Folks is Not Like the Others

Narcissistic Personality Disorder

"Narcissistic personality disorder (NPD) is a personality disorder in which the individual is described as being excessively preoccupied with issues of personal adequacy, power, prestige and vanity. This condition affects one percent of the population. First formulated in 1968, it was historically called megalomania, and is severe egocentrism." ~Wikipedia 

"Kernberg classified narcissism along a dimension of severity from normal to pathological and distinguished among high, middle, and low-functioning pathological narcissists. At the highest level, patients are able to achieve the admiration necessary to gratify their grandiose needs. These patients may function successfully during their lifetime, but are susceptible to breakdowns with advancing age as their grandiose desires go unfulfilled. At the middle level, patients present with a grandiose sense of self and have little interest in true intimacy. At the lowest level, patients present with comorbid borderline personality traits. These patients’ sense of self is generally more diffuse and less stable; they frequently oscillate between pathological grandiosity and suicidality. ~ Levy

Signs of NPD: 

Identify diffusion, primitive defenses, unstable reality demonstrating a facsimile of integration (Kernberg)
Rigid and brittle defenses
Unrealistic sense of grandeur
Aggressive and boastful
Excessive rage and angry hostility
Inability to forgive
Impaired sense of self (Payson)
Need to be admired, perceived as special
Envy, shame and guilt at other’s success
Poor self-awareness: little to no capacity to observe self
Rejects dependency (eliminates relationships with others)
Denial of attachment needs (Dimaggio)
Views others as hostile, inept, incompetent (Dimaggio)
Believes they are empathic when they aren’t (Dimaggio)
Overreacts when others set limits
Lack of engagement in work and love life
Marginally developed conscience (not fully developed)
Swings from hyper-valued to self-derogation (Dimaggio)
Aggressive reactions to perceived criticism and social rejection
States of emptiness, emotional numbing and devitalization (Dimaggio)
Did not learn to consider the needs of others/raised to see the self as “special”
Severe exploitation; possible criminality; feels above the rules and laws governing others
Sexual pathology (total inhibition or a chaotic sex life) 

See my post: Pathological Narcissism Worsens with Age; the Rest of Us Get Better
See my post: The DSM, Axis II, Cluster B
See my post: The X-Y-Z Files

Pathological Narcissism Plus +++ 

On the pathological section of the graph, a white downward arrow points toward another continuum ranging from narcissistic personality disorder to malignant narcissism to anti-social personality disorder to psychopathy. Grandiosity (self-importance), envy, high entitlement, high exploitation, and low empathy leads to callous and remorseless use of other people.  This degree of narcissism might include sadistic and/or violent behavior, even crimes. The antisocial personality disorder represents the most severe form of pathological narcissism.

Malignant Narcissism 

"A more severe level of superego dysfunction in people with a narcissistic personality structure has been captured by the term "malignant narcissism". This is a form of characterological functioning that falls between NPD and AsPD...people with malignant narcissism differ from people with AsPD since they still have the capability for loyalty and concerns for others, and for feeling guilty." ~(pg. 106) Ronningstam

"Kernberg contends that, despite the absence of depression, malignant narcissists are at high risk for suicide because such behavior represents sadistic control over others, a dismissal of a denigrated world, or a display of mastery over death." ~Levy

“The lower functioning NPD individual (in closer proximity to the sociopath on the continuum) will be prone to constantly bending the rules for himself although outwardly he may criticize others for a similar infraction or transgression…[he has] no remorse for the effects of his offenses on others and will rationalize his deceptive manipulations in any number of ways. The degree to which deceptive, harmful, and unlawful behaviors are present in an NPD individual is of utmost importance if you are in a significant relationship.” (pg. 19) Payson

Antisocial Traits
Paranoid features
Capacity to feel guilt
Take pleasure in aggressive and sadistic behavior towards others (and) self
Capable of loyalty and concern for others
Chronic suicidal behavior (as triumph)
Thrill-seeking, grandiose ecstasy (Ronningstam)
Self-righteous retaliation to maintain superiority (and restore self-esteem)
Ambitious striving for power and control (political dictators, tyrants, cult gurus)
Projection of darker traits onto others, splitting the world in two 

See my post: Normal or Malignant Narcissism?

Anti-Social Personality Disorder 

"The antisocial personality disorder (psychopathic) merits distinction from Cluster B disorders and may be considered a subgroup of the narcissistic personality". (pg. 228) Kernberg

"NPD and AsPD share interpersonal exploitativeness, lack of empathy and envy...Expoitative behavior, typical for both NPD and AsPD, may in narcissistic people be unconsciously motivated, a result of feeling superior or entitled, and serve to enhance self-image by gaining attention, admiration, and status. Exploitativeness can also stem from the narcissistic person having compromised empathy and being unable to identify the boundaries and feelings of others." (pg. 109-110) Ronningstam 

Failure to conform to social norms
Deceitfulness
Impulsivity
Irritability and aggressiveness
Reckless disregard for safety of self or others
Consistent irresponsibility
Lack of remorse
Callous unconcern for the feelings of others
Gross and persistent attitude of irresponsibility
Incapacity to maintain enduring relationships
Low frustration tolerance; low aggression threshold
Incapacity to experience guilt or to profit from experience
Blames others or offers plausible rationalizations (wikipedia link)

Psychopathy 

"Our psychopath, meanwhile, has no ethics, and thus no need for rationalizations. He has affairs because he wants to. Life, for him, is a game. The game is about figuring out how to get what he wants now, by whatever stratagems necessary. And it’s a game without rules. Without rules, there is no violation, no exploitation; and even if there is, it’s part of the game. So our psychopath makes up the rules as he goes along, duping this individual and that, lying like a shameless child as he improvises his way in and out of his schemes, sometimes smoothly, sometimes not—but always heedless of, and absolutely indifferent to, the damage he causes." ~Steve Becker 

Glibness/superficial charm
Grandiose sense of self-worth
Pathological lying
Cunning/manipulative
Lack of remorse or guilt
Shallow affect (genuine emotion is short-lived and egocentric)
Callousness; lack of empathy
Failure to accept responsibility for his or her own actions
Need for stimulation/proneness to boredom
Parasitic lifestyle
Poor behavioral control
Lack of realistic long-term goals
Impulsiveness
Irresponsibility
Juvenile delinquency
Early behavior problems
Revocation of conditional release
Criminal versatility (Hare and colleagues)  

Hare Psychopathy Checklist 

A Dimensional Measure

Trait narcissism
Social-Personality 

"Social-personality narcissism is associated with positive psychological well-being and high self-esteem (Sedikides et al., 2004); likewise, there is little evidence for the ‘‘brittleness’’ found in the clinical description, although there is evidence of externalizing, aggressive responding to certain provocations (e.g., Bushman & Baumeister, 1998). Nevertheless, the social-personality construct of narcissism does predict many of the behaviors noted in the clinical description (e.g., entitlement, fantasies of success, a desire for admiration)." ~Miller

Take the Narcissistic Personality Inventory (NPI) Test 

How'd you score on the test? The average score in the American population is 15.3 and the score for celebrities was 17.8. If you're unfamiliar with the NPI, Oprah.com published an explanatory article by Dr. Drew Pinsky referring to his book, The Mirror Effect. What type of narcissism was Dr. Pinsky measuring? Normal narcissism. Subclinical narcissism. People with 'high' rather than 'low' levels of functioning.

"Narcissism is a particular constellation of personality traits." ~Dr. Drew Pinsky. 

Those seven traits measured by the NPI are: Authority; Self-sufficiency; Superiority; Vanity; Entitlement; Exhibitionism; Exploitativeness. It's easy to remember all seven if you use this acronym for narcissism: ASSvEEE. I know, don't say it. How childish. "People at the psychologically healthy end of the narcissism continuum exhibit these traits in normal, moderated levels," Pinsky writes. "People at the other end manifest their narcissistic traits in such extreme ways that they demonstrate the pathologies of narcissistic personality disorder. In between lies a spectrum of infinite gradation."

Dr. Drew Pinsky thus validates my inclusion of personality traits on the narcissistic continuum graph. While there isn't solid research proving the Narcissistic Personality Inventory (NPI) fully captures maladaptive narcissism, I think it's reasonable to assume a high score on the NPI would equate to less-than-healthy narcissism. And I think the NPI might do a fair job pointing towards psychopathology, despite being a measure of subclinical/normal narcissism.

Some of the traits measured by the NPI are suggested to be adaptive such the association between Authority and positive personal adjustment, optimism, warmth, self-confidence, friendliness, etc. (Hill) But there are two traits in the constellation that are maladaptive with a potential for physical aggression. Those two traits aren't surprising: Exploitation and Entitlement, associated with competitiveness, suspiciousness, exhibitionism, being domineering, aggressive, acquisitive and ambitious. (Hill)

"[Our] research indicated that narcissistic entitlement and exploitativeness were the narcissistic subtraits that best predicted all measures of aggression. The findings support existing research that identifies these traits as particularly maladaptive traits of narcissism." (Reidy)

So instead of focusing on Vanity, the greater concern is narcissistic Entitlement and Exploitativeness. (Who cares if someone stares at their reflection in a pool?) If someone lacks empathy, is unable to recognize their impact on others, justifies feeling good about themselves no matter who gets hurt, then narcissistic traits like exploitativeness and entitlement could lead to a marriage proposal. Now you can call me cynical AND childish 

See my post: Therapy too Expensive? Wait'll You Have a Midlife Crisis!
See my post: Healthy narcissism and Self-Admiration
See my post: Take the Narcissistic Personality Inventory
See my post: Narcissistic Traits and the NPI

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"Freedom is choosing what you do with what's been done to you." ~John-Paul Sartre

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Develop An Action Plan

If you see yourself doing, saying, and thinking things that contradict the values and principles you have striven to live by, consider talking with professional therapists, religious leaders, counselors, etc. Include people in your recovery plan who are not family members. Many people with narcissistic personalities prefer a closed circle---relying on partners (family members or intimate friends) rather than asking for outside help. The fear of being shamed,  the humiliation of dependency or deficiency, makes it seem like a good idea to keep your problem in the family. But it's not. It's a terrible plan. It's one thing to fire your therapist because you realized he was an idiot. It's entirely worse to fire your spouse. Or your best friend. Always, always ask for therapeutic support beyond what family and friends can offer.

See my post: Resources for People with a Narcissistic Personality

Resources

A free download of Chapter Four in The Mirror Effect: "The Genesis of Narcissism"

Baumeister, RoyF. Jennifer Campbell, Joachim Krueger, and Kathleen Vohs. (2003) "Does High-Self-Esteem cause Better Performance, Interpersonal Success, Happiness or Healthier Lifestyles?" Psychological Science in the Public Interest 44-page pdf Article

Beattie, Melody. (1987) Codependent No More. Harper/Hazeldon Books

Becker, Steve. Differentiating Narcissists and Psychopaths

Bradshaw, John. (1988) The Family: A revolutionary way of self-discovery. Health Communications, Inc.

Brown, Nina W. (2001) Children of the Self-Absorbed. New Harbingers Publications

Brown, Nina W. (2003) Loving the Self-Absorbed. New Harbingers Publications

Brown, Nina W. (1998) The Destructive Narcissistic Pattern. Praegers Publishers

Brown, Sandra L. (2009) Women Who Love Psychopaths: Inside the Relationships of Inevitable Harm with Psychopaths, Sociopaths, & Narcissists. Mask Publishing

Campbell, Keith W. and Joshua D. Foster. “The Narcissistic Self: Background, an Extended Agency Model, and Ongoing Controversies.” 24-page pdf article

Dimaggio, Giancarlo. (2012) "Rethinking What We Know". Psychiatric Times

Erikson, Eric. Stages of psychosocial development

Hill, Robert and Gregory Yousey. (1998) "Adaptive and Maladaptive Narcissism among University Faculty, Clergy, Politicians, and Librarians" 8-page pdf article

Holmes, Jeremy. (2001) Narcissism (Ideas in Psychoanalysis). Totem Books

Hotchkiss, Sandy. Why is it Always About YOU? (2002) The Free Press

Johnson, Steven M. (1987) Humanizing the Narcissistic Style.W.W. Norton & Company (pdf)

Kernberg, Otto. (1992) Borderline Conditions and Pathological Narcissism. Jason Aronson, Inc. 

Kohut, Heinz. (1977). The Restoration of the Self.  International Universities Press.

Lancer, Darlene. (2012) Symptoms of Codependency PsychCentral

Levy, Kenneth. (2012) "Subtypes, Dimensions, Levels, and Mental States in Narcissism and

Narcissistic Personality Disorder". Journal of Clinical Psychology: In Session

Lowen, Alexander. (1985) Narcissism: Denial of the True Self. Touchstone books

Maccoby, Michael. (2003) The Productive Narcissism: The Promise and Peril of Visionary Leadership. Broadway Books

Malin, Arthur. "Psychotherapy of the Narcissistic Personality Disorders". Review of Psychiatry, Volume 9. 16-page pdf link 

Miller, Joshua and Keith Campbell. "Comparing Clinical and Social Personality Conceptualizations of Narcissism". 29-page pdf

Oakley, Barbara. (2011) Pathological Altruism. Oxford University Press

Payson, Eleanor D. (2002) The Wizard of Oz and Other Narcissists: Coping with the One-Way relationship in Work, Love and Family. Julian Day Publications

Pinsky, Drew and Mark Young. (2006) "Narcissism and Celebrity". Journal Research in Personality 9-page pdf article

Pinksy, Drew and Mark Young. (2009) The Mirror Effect: How Celebrity Narcissism is Seducing America. HarperCollins (pdf download of Chapter Four)

Rappoport, Alan. "Co-Narcissism: How We Accommodate to Narcissistic Parents". pdf article

Raskin & Terry (1988) Narcissistic Personality Inventory (NPI) Wikipedia page

Reidy Dennis, Amos Zeichner, Josh Foster, Marc Martinez. "Effects of narcissistic entitlement and exploitativeness on human physical aggression." Science Direct link

Ronningstam, Elsa F. (2005) Identifying and Understanding the Narcissistic Personality. Oxford University Press.

Ronningstam, Elsa and John Gunderson. (1996) Narcissistic Personality: A Stable Disorder or a State of Mind?  Psychiatric Times

Russ, Eric and Jonathan Shedler, Rebekah Bradley, Drew Westen. "Refining the Construct of Narcissistic Personality Disorder: Diagnostic Criteria and Subypes." Am J Psychiatry 165:11, November 2008. 9-page pdf article

Sedikedes, Constantine, Aiden Gregg, Eric Rudich, Madoka Kumashiro and Caryl Rusbult. "Are Normal Narcissists Psychologically Healthy?: Self-Esteem Matters" pdf article

Silverstein, Marshall L. (2006) Disorders of the Self: A personality Guided Approach. American Psychological Association pdf article

Stone, Michael H. (2008) “Normal Narcissism: An Etiological and Ethological Perspective,” Disorders of Narcissism: Diagnostic, Clinical and Empirical Implications by Elsa Ronningstam, editor.  

Swartz, Allan. "The Narcissist versus the Narcissistic Personality Disorder" on MentalHelp.net

Symington, Neville. (1993) A New Theory. Karnac Books.

Tamborski, Michael and Ryan P. Brown. (2012) "The Measurement of Trait Narcissism in Social-Personality Research" Link

Twenge, Jean and W. Keith Campbell. (2009) The Narcissism Epidemic: Living in the Age of Entitlement. Free Press

Twenge, Jean, Sara Konrath, Joshua Foster, Keith Campbell and Brad Bushman (2008). "Egos Inflating Over Time: A Cross-Temporal Meta-Analysis of the Narcissistic Personality Inventory". Journal of Personality 28-page pdf article 

Whitfield, Charles. (1991) Co-dependence: Healing the Human Condition. Health Communications, Inc.

Zomerland, Gudrun. Narcissism and Co-narcissism.