Narcissism at the crossroads: Phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis Nicole M. Cain a, ⁎ , Aaron L. Pincus a , Emily B. Ansell b a The Pennsylvania State University, United States b Yale University School of Medicine, United States Received 5 March 2007; received in revised form 18 September 2007; accepted 24 September 2007 Abstract This review documents two themes of emphasis found in phenotypic descriptions of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clinical theories of narcissism spanning 35 years consistently describe variations in the expression of pathological narcissism that emphasize either grandiosity or vulnerable affects and self- states. Recent research in social/personality psychology examining the structure of narcissistic personality traits consistently finds two broad factors representing Grandiosity–Exhibitionism and Vulnerability–Sensitivity–Depletion respectively. However, the majority of psychiatric criteria for narcissistic personality disorder (NPD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) emphasize expressions of grandiosity. By placing most of the diagnostic emphasis on overt grandiosity, DSM NPD has been limited by poor discriminant validity, modest levels of temporal stability, and the lowest prevalence rate on Axis II. Despite converging support for two phenotypic themes associated with pathological narcissism, psychiatric diagnosis and social/personality psychology research often focus only on grandiosity in the assessment of narcissism. In contrast, clinical theory struggles with a proliferation of labels describing these broad phenotypic variations. We conclude that the construct of pathological narcissism is at a crossroads and provide recommendations for diagnostic assessment, clinical conceptualization, and future research that could lead to a more integrated understanding of narcissistic personality and narcissistic personality pathology. © 2007 Elsevier Ltd. All rights reserved. Contents 1. Clinical theories of narcissism ............................................ 640 2. Narcissism in social/personality psychology ..................................... 642 2.1. Self-regulation theory ............................................. 643 2.2. Empirical associations of the NPI ....................................... 643 2.3. NPI scores and self-esteem .......................................... 643 2.4. Pathological narcissism and the NPI ...................................... 644 Available online at www.sciencedirect.com Clinical Psychology Review 28 (2008) 638 – 656 ⁎ Corresponding author. E-mail address: nmc179@psu.edu (N.M. Cain). 0272-7358/$ - see front matter © 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2007.09.006