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NPD, GRANDIOSE, VULNERABLE, & TRAIT NARCISSISM EXPLAINED USING SCHOLARLY RESEARCH
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[Music]
Hi everyone, I'm Dr. Peter Serno,
retired licensed psychotherapist,
personality disorder specialist, and
featured expert in Hulu's Ted Bundy
Dialogue with the Devil docue series. In
today's video, I am going to address
three key issues. False accusations that
I'm lying about DSM criteria. the
problem when influencers misrepresent
what the DSM means without proper
training and why it's unprofessional for
influencers and clinicians to publicly
disrespect others without direct
dialogue. Normally, I wouldn't entertain
or respond to public nonsense. However,
when that public nonsense escalates to
slander and defamation of character and
false accusations, I have to address it.
But I'm going to address it in a
professional manner. Let's be crystal
clear. The DSM, the Diagnostic and
Statistical Manual of Mental Disorders,
is a clinical tool, not a social media
playbook. It requires training, nuance,
and context to interpret accurately.
You're not doing anyone a favor by
spinning it for likes. The DSM is and
always will be an evolving science. It's
not intended for use outside the context
of clinical research, diagnosis, and
treatment. It's not a social media desk
reference, and it's not dogma. It's not
the Bible of psychology or psychiatry,
and it doesn't claim to be, although
many people misuse it that way. It's a
practical manual for everyday
professional work. just to highlight how
it can be wrong and has been wrong in
the past. It wasn't long ago that
homosexuality was classified as a mental
disorder in the DSM. In the first DSM,
it was listed under sociopathic
personality disturbance as a sexual
deviation. In 1968, it moved to sexual
deviations alongside pedophilia. In
1973, the APA voted to remove it as a
disorder with a compromise, sexual
orientation disturbance. In 1980, the
DSM introduced egoistonic homosexuality.
And then in 1987, homosexuality was no
longer listed as any kind of disorder.
Other examples of outdated and harmful
diagnoses were also removed, including
hysteria, present in DSM 1 and 2,
removed for being sexist and
unscientific. masochistic personality
disorder was drafted in the 1987 DSM and
it was a proposed personality disorder
to describe people who repeatedly chose
abusive relationships. It was removed
after criticism that it was victim
blaming and it certainly should have
been. The lesson here, the DSM is useful
but not infallible and it will continue
to change. Everything in it requires
training, nuance, and professional
responsibility to interpret properly.
Now, disagreements among professionals
are healthy. They actually advance our
field. But what crosses the line is
using condescension and attacking
someone's character personally and
publicly without seeking clarification.
That is not professionalism, and it sets
the wrong example for those we aim to
serve. Here's where all of this started.
I was interviewed in the past by a
gentleman named Jared Melo. We were
discussing the popular myth that all
narcissists are secretly insecure. My
statement said, "Most narcissists, in
fact, are not insecure. I was accused of
lying, fabricating research, and
ignoring peer-reviewed research that
disproves this claim." The individual
who had an issue with this actually
referred to me as a narcissist in a
comment on one of my other posts all the
way back in the beginning of last year
and basically stated, "I'm a narcissist
because I have suggested that there is a
heritable component to narcissism based
on the research I shared." He didn't ask
me if he could see the research. He
simply said, "I seem like a narcissist
because I'm sharing the research." This
escalated to him publicly calling me a
liar. So, let's look at some
peer-reviewed research so that I can
explain why I said what I said. This
comes from the handbook of trait
narcissism. Extant data suggests that
vulnerable narcissism represents a
construct that is largely divergent from
NPD and grandiose narcissism. And why is
it largely divergent? To finish the
quote, it's composed of the tendency to
experience a wide array of negative
emotions such as depression,
self-consciousness, stress, anxiety, and
urgency. So, right here, these authors
are differentiating between vulnerable narcissism
narcissism
and NPD, which is the DSM diagnosis.
Further research demonstrates the
following. I quote, "Grandio narcissism
is associated with grandiosity,
entitlement, high self-esteem,
interpersonal gregariousness, and
assertiveness." This comes from the
peer-reviewed journal, Personality
Disorders Theory, Research, and
Treatment. And here's another article
that is peer-reviewed. Grandiose
narcissism showed a stronger association
with NPD.
So, what does this mean? The grandiose
phenotype is the one most mapped onto
DSM criteria for NPD. So when I said
most narcissists are not insecure, did I
lie? Not according to John's Hopkins
University Research and other
peer-reviewed sources from the Handbook
of Trait Narcissism and the scholarly
journal Personality Disorders theory
Research and Treatment. Now that we got
that out of the way, let's look deeper
into vulnerable narcissism. Vulnerable
narcissism is not a DSM5 TR diagnosis.
It's a research subtype marked by hyper
sensitivity, shame, and emotional
instability. Let's look at the DSM5
alternative model for personality
disorders. In the DSM on pages 887 to
888, we see to diagnose NPD, we have
moderate or greater impairment in
personality functioning manifested by
characteristic difficulties in two or
more of the following areas: identity,
self-direction, empathy, intimacy, one
of which references emotional regulation
and mirrors fluctuations in self-esteem,
but does not state that it has to be
present. Hence two or more not this one
always. The following personality traits
have to be present. Not can be or maybe
have to be. Grandiosity
feelings of entitlement either overt or
covert. Firmly holding to the belief
that one is better than others and
condescending toward others.
Neuroscience has proven. Look at the
work of Lisa Feldman Barrett. We feel
what we believe. We do not unconsciously
feel the opposite of what we believe. In
moments where I experience profound fear
of criticism or rejection, I am not unconsciously
unconsciously
brimming with confidence. If I believe I
am in danger, I feel like I'm in danger.
Similarly, if someone firmly holds the
belief that they are better than others,
as is the case with this necessary
component of narcissism and NPD, not
optional, necessary component, that
means they feel superior, not inferior.
They feel secure, not insecure. This
does not mean that individuals who are
narcissistic don't sometimes feel
insecure or experience moments of shame.
That's not what I'm saying. It means
that insecurity and shame don't fuel the
engine of narcissism. Grandiosity does,
which is the opposite of inferiority and
shame. Now we move on to associated
specifiers. In the DSM, it says that
traits of negative affectivity,
including depressivity and anxiousness,
can be specified to record more
vulnerable presentations. These are
associated features and specifiers, not
criteria. Now, here's where research on
vulnerable narcissism gets really
interesting. To me, it's interesting, so
I like to share it. It's not
controversial to me. It's just
interesting. I would like everybody to
please remember that this is not my
research. It's the research of experts.
I'm simply sharing it. Here's a quote
from a peer-reviewed research article.
Vulnerable narcissism was significantly
associated with borderline personality
disorder symptomatology, whereas
grandiose narcissism aligned more with
NPD. Further, Miller and colleagues
concluded, quote, "Vulnerable narcissism
is predominantly a disorder of
neuroticism marked by anxiety,
depression, self-consciousness, and
emotional instability." You know what is
not a disorder of neuroticism? As we
just saw in the alternative model or the
dimensional model for personality
disorders, neurotic traits were not
listed as necessary criteria of
narcissistic personality disorder. The
trait that was listed as a necessary
feature, the primary feature in fact was
grandiosity. Grandiosity falls under the
domain of antagonism, not neuroticism.
Additional findings include grandiose
narcissism showed a stronger association
with NPD, whereas vulnerable narcissism
was only associated with BPD. A
vulnerable narcissism composite score
manifested a nearly identical pattern of
correlations with general personality
traits, ideological variables, and
criterion variables, as did a borderline
PD composite. Nobody's making this up.
Here's the synthesis. Vulnerable
narcissism, according to research,
mirrors BPD symptomatology much more
than grandiose dominanceoriented traits
of classic NPD. Again, not lying, just
sharing alternative perspectives that
most people don't even know exist. This
research clearly upsets a lot of people
who cannot admit that they may have been
wrong about a few things in the past,
that believe old theories are set in
stone and should not be touched in any
way, shape, or form. I wonder if we
should treat research on cancer or
autism or dementia in the same way.
Should we solely rely on research
conducted in the early 1900s and mid
1900s to understand those conditions?
Here is another big confusion related to
narcissism. People equate narcissism
with low self-esteem as if low
self-esteem is the engine that drives
narcissistic traits and tendencies.
Here's another quote from a
peer-reviewed research article published
in the Handbook of Trait narcissism
volume. A growing body of research shows
that narcissism and self-esteem are only
weakly related because quote narcissism
and self-esteem are rooted in distinct
core beliefs. Going back to another
source from earlier, grandiose
narcissism is associated with
grandiosity, entitlement, high
self-esteem, interpersonal
gregariousness, and assertiveness. And
as I already mentioned earlier, the
grandiose phenotype is the one most
mapped on DSM criteria for NPD. So the
one most mapped onto DSM criteria for
NPD is the one that is associated with
high self-esteem.
Hence why I said most narcissists are
not insecure and don't suffer from low
self-esteem. This is why conflating low
self-esteem with narcissism is a
categorical error. Hopefully, people
will now see that there is peer-reviewed
research that exists that validates what
I said in the interview. Now, this is
something that I'm going to say that I'm
sure is going to surprise a lot of
people. Narcissism is weakly related to
self-esteem in general. Both high and
low self-esteem, high self-esteem or low
self-esteem, they are not the driving
force of narcissism. Let's look more
closely into the driving force of
narcissism that is actually problematic.
This comes from a peer-reviewed research
article on narcissism. Narcissists
believe they are inherently superior to
their fellow humans. They hold exalted
views of themselves even if such views
conflict with reality. One of the
trainings that I attended over 10 times
in my career that qualified me to become
a certified personality disorder
treatment provider and specialist was
under Dr. Gregory Lester. Dr. Lester's
private office served as one of the
original research sites of the DSM5
revision of the personality disorder
section. Here is what he has to say
about narcissists in his training. The
problem with narcissists is even when
they are not good at something, they
still think they are wonderful. Their
problem is grandiosity. It's not low self-esteem.
self-esteem.
It's inappropriate
misapplied self-confidence.
This is a nuance that really needs to be
understood. And this is why
professionals need to be trained by
professionals who know what they're
talking about. It's not whether or not
narcissists feel low self-esteem,
fragile self-esteem, or even have high
self-esteem. The problem is they hold
themselves in high regard even when
there's evidence contrary to that. They
think the world of themselves even when
they can't back it up. It's an unearned, undeserved
undeserved
self-confidence that they feel entitled
to even when they can't back it up.
That's the problem. It's that
grandiosity that causes problems in the
lives of others. It's not their
self-esteem. If low self-esteem and
self-doubt are what plague narcissists,
they would be easy to deal with. Low
self-esteem and self-doubt are not the
kind of interpersonal dynamics that
cause so much pain in the lives of
others. Lots of people live with low
self-esteem and self-doubt and never
cause the kinds of problems that
narcissists do because they don't
antagonize others the way narcissists
do. Trauma victims, by contrast, can
maintain good character and kindness
even while carrying profound shame and
low self-esteem. This shows us that
self-esteem, even if it's experienced as
fragile or low at times, is not the
problem. The real problem, the engine of
narcissism, is grandiosity. Consider
this comparison. Low self-esteem,
sensitivity to criticism, and feelings
of inferiority are core features of
avoidant personality disorder. So, why
don't we just call narcissists avoidance
instead? because their presentation is
fundamentally different. Avoidance are
not antagonistic. If they were, they
would be just as difficult as
narcissists to deal with. The DSM spells
out this distinction clearly. With
narcissistic personality disorder, some
individuals with narcissistic
personality disorder intentionally and
purposefully take advantage of others
emotionally, socially, intellectually,
and financially for their own purposes
and gains. with avoidant personality
disorder. The low self-esteem and hyper
sensitivity to rejection are associated
with restricted interpersonal contacts.
I'm not comparing which disorder is
worse. I'm simply pointing out that the
engine driving narcissism even when
self-esteem is fragile is grandiosity
and that is what leads to the
mistreatment of others. With avoidant
personality disorder, low self-esteem
leads to withdrawal and avoidance.
Grandiosity in the narcissist rooted in
antagonism leads to exploitation. This
is why self-esteem is not the issue. We
can harp on it and argue about it all
day long, but the reality is some
narcissists experience high self-esteem.
Some narcissists experience low
self-esteem. Some narcissists experience
fluctuations. Some narcissists
experience fragile self-esteem. Guess
what? So do individuals with avoidant
personality disorder. So do individuals
with depression. So do individuals with
anxiety. So do individuals who have no
mental disorders whatsoever.
Self-esteem fluctuates in life, but it's
not the driving force that makes
narcissists problematic. Now, this is
going to be one of my favorite sections
of this video. I hope you enjoy this. I
get a lot of people throwing the term
peer-reviewed in my face as if I didn't
earn a doctorate in psychology and I
don't know what the hell peer-reviewed
research means. Here's what I found out.
Most critics of me do not have a clue
what peer reviewed actually means. So, I
hope they are listening because now I'm
going to explain it the way you would
understand it if you went to school.
Where is the peer-reviewed research? I
have peer-reviewed research that shows
you don't know what you're talking
about. I get these comments a lot. As
you can see in this video, I have
already demonstrated that I do in fact
have peer-reviewed research to support
my claims. But let's define what peer
reviewed actually means. Peer review is
the process by which an academic journal
sends a submitted manuscript to other
scholars in the same field to evaluate
its clarity, logic, citations, and
adherence to the journal's standards. If
it passes, it's published. If not, it's
rejected or revised. That process
matters. It helps filter out poorly
written or unsupported work. But here's
the nuance. Peer review only means that
the paper met the editorial standards of
the journal. Many theoretical papers are
peer-reviewed, but their claims have not
held up to empirical testing. Entire
schools of psychoanalytic theory once
dominated journals. Melanie Klene,
Margaret Mer, Donald Winnott, Ronald
Fairbar, Hines Kohut, Otto Kernberg.
Their work is cited as if it is
evidence, but in reality, much of it was
opinion and speculation built upon the
assumption that we already knew all the
causes of psychopathology. In reality,
it was correlation without causation.
Peer-reviewing a research article is not
the same thing as saying that it is true
and accurate. Peer-reviewed research
does not make something true. To make
something true or accurate, it needs to
be based on controlled studies that can
be replicated and verified. A couple
examples of these genetic twin studies,
neurobiological imaging, longitudinal
designs, and quantitative analyses.
These controlled methods generate data
that can be tested again and again, not
simply asserted subjectively. In other
words, peer review is just a gateway to
publication. It's not synonymous with
truth. Empirical replication is the
gateway to truth. You can't just say
it's peer-reviewed and call it a day. It
has to be empirically replicated
objectively for validity. So, when my
critics argue that there's no
peer-reviewed research, not only are
they factually wrong, they are misusing
the term. The studies I reference come
from the APA and other empirical
journals. They meet the gold standard of
science. Evidence that is testable,
replicable, and falsifiable, and that
are peer- reviewviewed. A lay person who
thinks that peer review is synonymous
with truth is not properly educated or
informed. Now, let's look at something
else that's very interesting about
diagnoses like NPD.
NPD is a heterogeneous diagnosis. NPD's
diagnosis in the DSM5 and DSM5 TR
requires only five of nine possible
criteria producing vast heterogeneity.
One way to look at heterogeneity is
through the combinations. There are 256
possible ways to meet the threshold. We
also have something called phenotypic
heterogeneity. Traits vary. Some
emphasize grandiosity, others
vulnerability. So mathematically there
are 256 possible combinations. These
cluster into 126 distinct profiles. Some
resemble vulnerable presentations,
others grandiose. Let's go to the DSM5
TR page 761, which gets quoted often to
somehow show that I have no idea what
I'm talking about. Individuals with this
disorder, NPD, require excessive
admiration. Their self-esteem is almost
invariably fragile and their struggle
with severe internal self-doubt,
self-criticism, and emptiness results in
their need to actively seek others
admiration. Wonderful. Here's the
crucial point. That description is one
criterion, but it is not required
because only five of the nine criteria
are necessary. A person can be diagnosed
with NPD without ever showing fragile
self-esteem, self-doubt, or excessive
admiration seeking. One patient may
present with arrogance, entitlement, and
exploitation without insecurity, while
another may present with
hypersensitivity and withdrawal. Both
still qualify for the same diagnosis.
The key takeaway is that not every
patient with NPD looks the same.
Heterogeneity complicates diagnosis.
There can also be overlap with other
personality disorders, and so
interpreting NPD requires the capacity
for nuance. As I've shared research
earlier in this video, the grandiose
phenotype is the one most mapped onto
DSM criteria for NPD. And the grandiose
phenotype is the one that's associated
with grandiosity, entitlement, high
self-esteem, interpersonal
gregariousness, and assertiveness. The
reason why the peer-reviewed research
that insists that shame and low
self-esteem and insecurity are the
driving forces of narcissistic
personality disorder, the reason why
those theories are so problematic is
because there are so many exceptions to
them. But instead of acknowledging the
exceptions, they simply say, "Well, we
already know everything we need to know,
and so if anybody else researches
anything else," they're wrong. Period.
That is not any way to conduct research.
As I stated earlier, recently I was
publicly defamed by a lay person who
goes by the name of Batwolf on
Instagram. He stitched a video of an
interview with me with a video of Dr.
Mark Etinson to label me a liar. He
claimed I fabricated research, which I
just demonstrated I did not. I want to
touch quickly on Dr. Mark Etinson. While
we may disagree on certain points, he is
a licensed professional. I also am a
licensed professional. Professionals can
and do disagree. That's how scholarship
advances actually. But lay antagonists
like Batwolf exploit these disagreements
to justify hostility, defamation, and
harassment. Pairing my remarks with
another clinician in a video the way
Batwolf did actually showcases my point.
Professionals can disagree thoughtfully.
His attempt at jabbing and defaming me
just highlighted who the professional
actually is. False accusations like this
highlight a very important lesson.
Disagreement is healthy. Antagonistic
impulsive misrepresentation is not. It's
slander and defamation of character. And
all of this could have been prevented if
he just had the decency to reach out to
me and politely request my peer-reviewed
research. I have consistently been
accused of being a reductionist, a
determinist. And the reality is people
take a one minute clip of a particular
thing I said. They completely ignore
nuance. They completely ignore the gray
area. They don't have the capacity to do
anything other than dichotomize. And
when they do that, they run the risk of
falsely accusing me, getting reactive
for no reason instead of just clarifying
things politely and respectfully. If you
read my book, you will see that I am not
a reductionist or a determinist. I'm not
an environmental determinist and I'm not
a biological determinist. I'm somebody
who is looking to bridge the gap between
science and clinical practice. I'm
somebody who is interested in bridging
the gap related to exceptions to these
rules in research that people ignore or
dismiss due to confirmation bias rather
than looking at the reality. We don't
know everything we're ever going to need
to know. So, we need to keep doing more
research to fill in the gaps. I like
that. To me, that's the responsible
thing to do. You can hate my
presentation. You can hate the way I
look. You can hate my tone of voice.
Whatever it is you want to hate, go
ahead. Those are your opinions. Those
are your experiences. No problem there.
But when you falsely accuse me of making
stuff up that is as serious as the
disorders in the DSM, when you falsely
accuse me of making stuff up about that,
that's where I draw the line. Thank you
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