APA Citation
Ronningstam, E. (2013). An update on narcissistic personality disorder. *Current Opinion in Psychiatry*, 26(1), 102-106. https://doi.org/10.1097/YCO.0b013e328358646a
Summary
Elsa Ronningstam, the world's leading clinical authority on narcissistic personality disorder, provides an update on NPD research and clinical understanding. She addresses the core features of NPD (grandiosity, self-enhancement, and vulnerable states), discusses the debate over NPD's inclusion in DSM-5, reviews treatment approaches, and examines the relationship between narcissism and suicidality. The review emphasizes that NPD involves both grandiose presentations and underlying vulnerability, with shame being a central but often hidden feature.
Why This Matters for Survivors
This clinical update from the foremost NPD expert validates what many survivors observe: that the narcissist's grandiosity masks profound vulnerability. Understanding that NPD involves both the entitled behavior you experienced and hidden shame/fragility helps explain the extreme reactions to perceived slights. Ronningstam's work bridges clinical understanding and lived experience.
What This Research Establishes
NPD involves both grandiosity and vulnerability. The diagnostic criteria emphasize grandiosity, but clinical understanding recognizes underlying vulnerability—shame, fragility, hypersensitivity—that the grandiose presentation defends against.
Shame is central but hidden. Narcissistic behavior often functions to avoid experiencing shame. When defenses fail and shame breaks through, severe reactions follow. This helps explain the extreme responses to seemingly minor criticisms.
NPD is a distinct clinical entity. Despite debate over its diagnostic status, NPD represents a recognizable pattern requiring specific clinical approaches. It’s not just “extreme selfishness” but a structured personality organization.
Treatment is possible but requires specialized approaches. Effective treatment addresses both grandiose defenses and underlying vulnerability, building genuine rather than defensive self-esteem. Treatment is long-term and challenging but can produce meaningful change.
Why This Matters for Survivors
Understanding the contradiction you observed. You may have seen the narcissist oscillate between grandiose confidence and extreme sensitivity. This review explains these as two aspects of the same condition—grandiosity defending against underlying vulnerability.
Making sense of extreme reactions. The rage you faced when offering mild criticism reflects the narcissist’s core vulnerability being triggered. The response was about their internal state, not about what you said.
It’s a recognizable clinical pattern. What you experienced is a documented personality disorder with consistent features across individuals. You weren’t dealing with random bad behavior but a structured pattern clinicians recognize.
Understanding treatment realities. NPD can be treated, but treatment requires the narcissist to acknowledge vulnerability they’ve spent a lifetime defending against. This explains why they’re unlikely to seek or persist in treatment without external pressure.
Clinical Implications
Assess for both presentations. Narcissistic patients may present as either grandiose or vulnerable depending on circumstances. Assessment should explore both dimensions.
Address shame carefully. Shame is often the narcissist’s core experience, and interventions that increase shame may backfire. Treatment should build genuine self-esteem rather than simply confronting grandiosity.
Monitor suicide risk. NPD is associated with suicide risk, particularly following narcissistic injuries that breach defenses. This risk may be underrecognized clinically.
Educate about the disorder. Both patients and families benefit from understanding NPD as a structured pattern with both defensive and vulnerable features, not simply “selfishness.”
How This Research Is Used in the Book
Ronningstam’s clinical wisdom appears throughout chapters on NPD:
“Elsa Ronningstam, the world’s leading authority on narcissistic personality disorder, emphasizes what survivors often observe but struggle to name: the narcissist’s grandiosity masks profound vulnerability. The rage you triggered wasn’t about your words—it was about their inner fragility being touched. Understanding this doesn’t excuse the behavior, but it helps explain why minor criticism provoked major explosions. Their defensive structure was protecting against experiencing the shame that lies at their core.”
Historical Context
This 2013 review appeared during significant debate about NPD’s diagnostic future. The DSM-5 revision process considered eliminating NPD as a distinct diagnosis, folding it into a dimensional trait model. Ronningstam was among clinicians who argued successfully for retaining NPD, emphasizing its clinical utility and distinctiveness.
The review represents clinical wisdom accumulated over decades of working with narcissistic patients—wisdom that validates what survivors observe while providing clinical framework for understanding. Ronningstam’s work bridges research findings and clinical reality, making NPD comprehensible to clinicians treating it.
Further Reading
- Ronningstam, E. (2005). Identifying and Understanding the Narcissistic Personality. Oxford University Press.
- Ronningstam, E. (Ed.). (1998). Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. American Psychiatric Press.
- Caligor, E., et al. (2015). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5), 415-422.
- Pincus, A.L., & Lukowitsky, M.R. (2010). Pathological narcissism and narcissistic personality disorder. Annual Review of Clinical Psychology, 6, 421-446.
About the Author
Elsa Ronningstam, PhD is Associate Clinical Professor of Psychology at Harvard Medical School and Clinical Psychologist at McLean Hospital. She is widely considered the leading clinical authority on narcissistic personality disorder.
Ronningstam has authored or edited multiple books on NPD, including *Identifying and Understanding the Narcissistic Personality* and *Disorders of Narcissism*. Her clinical and research work has shaped modern understanding of NPD.
Historical Context
This 2013 review appeared during debate over whether NPD would be retained in DSM-5. Some proposed eliminating NPD as a separate diagnosis; Ronningstam and others argued successfully for its retention. The review represents clinical wisdom at a moment when NPD's diagnostic status was being reconsidered.
Frequently Asked Questions
NPD centers on three areas: self-regulation (grandiosity, superiority, self-enhancement), interpersonal patterns (entitlement, lack of empathy, exploitativeness), and emotional vulnerability (shame, envy, rage, especially when self-esteem is threatened). The grandiose presentation often masks underlying fragility.
Beneath the confident exterior, narcissists experience profound vulnerability—sensitivity to criticism, shame, fear of inadequacy. This vulnerability is usually hidden but erupts when their self-image is threatened. Understanding this helps explain their extreme reactions to minor slights.
Ronningstam emphasizes that shame underlies much narcissistic behavior but is rarely acknowledged. The grandiosity, rage, and entitlement often serve to protect against experiencing shame. When shame breaks through, it can trigger severe reactions including suicidality.
Yes, though treatment is challenging. Ronningstam reviews approaches including psychodynamic therapy, transference-focused therapy, and supportive interventions. Treatment requires addressing both the grandiose defenses and underlying vulnerability while building capacity for genuine self-esteem.
Some researchers proposed eliminating NPD as a separate diagnosis in DSM-5, arguing it overlapped too much with other disorders. Clinicians like Ronningstam argued NPD represents a distinct pattern requiring specific treatment approaches. NPD was ultimately retained.
Ronningstam notes that NPD is associated with suicide risk, particularly when narcissistic defenses fail and the person is flooded with shame or faces major narcissistic injury. The link between NPD and suicide has been underrecognized clinically.
Grandiose narcissism involves overt superiority, entitlement, and lack of empathy. Vulnerable narcissism involves hypersensitivity, shame, and insecurity beneath a defensive grandiose exterior. Most narcissists shift between these presentations depending on circumstances.
Understanding that the narcissist's behavior reflects both entitled grandiosity and underlying fragility helps make sense of their contradictory presentations. It also helps survivors understand that the extreme reactions to criticism weren't about them—they triggered the narcissist's core vulnerability.