Self-reported narcissistic traits in patients with addiction through the lens of the ICD-11 model for personality disorders

Abstract

Background
There is a presumption that pathological narcissism, or narcissistic personality disorder per se, can be considered a precursor to addiction. Although the ICD-11 model does not distinguish specific personality disorders, narcissistic psychopathology should be captured through personality trait qualifiers.

Objectives
To verify the capacity of the ICD-11 model in the detection of narcissistic psychopathology in patients with addiction; to test its discrimination capacity, convergent validity, and specificity toward the gender and the type of addiction.

Materials and methods
Two samples were employed in the study. Sample 1 (n = 421) consisted of patients with addiction; Sample 2 (n = 567) consisted of general population volunteers. Age range was 18–75 years and a battery of self-assessment questionnaires containing Personality Inventory for DSM-5–Brief Form Plus Modified; Triarchic Psychopathy Measure; Hypersensitive Narcissism Scale; and Level of Personality Functioning Scale-Self-Report was administered by pencil-and-paper method.

Results
The following was confirmed: (1) capacity of the ICD-11 model in relation to capture narcissistic pathology; (2) the differentiation capacity between the clinical and non-clinical population; (3) gender specificity in relation to grandiose and vulnerable narcissism; (4) the connection between the overall degree of impairment in personality functioning and most of trait qualifiers; (5) certain specifics of patients with addiction in relation to the type of addiction.

Conclusion
Results support the empirical and clinical relevance of the ICD-11 model in capturing narcissistic pathology in addicted patients. Clinical implications concerning assessment and treatment in addiction settings, and certain limits regarding the Anankastia domain are discussed.

Full text

fpsyt-13-1041480 November 23, 2022 Time: 7:29 # 1
TYPE Original Research
PUBLISHED 25 November 2022
DOI 10.3389/fpsyt.2022.1041480
OPEN ACCESS
EDITED BY
Bo Bach,
Psychiatry Region Zealand, Denmark
REVIEWED BY
Tim Bastiaens,
University Psychiatric Center KU
Leuven, Belgium
Mark Freestone,
Queen Mary University of London,
United Kingdom
Ava Green,
City, University of London,
United Kingdom
Elizabeth Huxley,
Australian National University, Australia
*CORRESPONDENCE
Karel D. Riegel
kareldobroslav.riegel@vfn.cz
SPECIALTY SECTION
This article was submitted to
Psychopathology,
a section of the journal
Frontiers in Psychiatry
RECEIVED 11 September 2022
ACCEPTED 08 November 2022
PUBLISHED 25 November 2022
CITATION
Riegel KD, Schlosserova L and
Zbornik TS (2022) Self-reported
narcissistic traits in patients with
addiction through the lens of the
ICD-11 model for personality
disorders.
Front. Psychiatry 13:1041480.
doi: 10.3389/fpsyt.2022.1041480
COPYRIGHT
© 2022 Riegel, Schlosserova and
Zbornik. This is an open-access article
distributed under the terms of the
Creative Commons Attribution License
(CC BY). The use, distribution or
reproduction in other forums is
permitted, provided the original
author(s) and the copyright owner(s)
are credited and that the original
publication in this journal is cited, in
accordance with accepted academic
practice. No use, distribution or
reproduction is permitted which does
not comply with these terms.
Self-reported narcissistic traits
in patients with addiction
through the lens of the ICD-11
model for personality disorders
Karel D. Riegel*, Lucia Schlosserova and Tadeas S. Zbornik
Department of Addictology, First Faculty of Medicine, Charles University and General University
Hospital in Prague, Prague, Czechia
Background: There is a presumption that pathological narcissism, or
narcissistic personality disorder per se, can be considered a precursor
to addiction. Although the ICD-11 model does not distinguish specific
personality disorders, narcissistic psychopathology should be captured
through personality trait qualifiers.
Objectives: To verify the capacity of the ICD-11 model in the detection
of narcissistic psychopathology in patients with addiction; to test its
discrimination capacity, convergent validity, and specificity toward the gender
and the type of addiction.
Materials and methods: Two samples were employed in the study. Sample 1
(n= 421) consisted of patients with addiction; Sample 2 (n= 567) consisted
of general population volunteers. Age range was 18–75 years and a battery
of self-assessment questionnaires containing Personality Inventory for DSM-
5–Brief Form Plus Modified; Triarchic Psychopathy Measure; Hypersensitive
Narcissism Scale; and Level of Personality Functioning Scale-Self-Report was
administered by pencil-and-paper method.
Results: The following was confirmed: (1) capacity of the ICD-11 model
in relation to capture narcissistic pathology; (2) the differentiation capacity
between the clinical and non-clinical population; (3) gender specificity in
relation to grandiose and vulnerable narcissism; (4) the connection between
the overall degree of impairment in personality functioning and most of trait
qualifiers; (5) certain specifics of patients with addiction in relation to the
type of addiction.
Conclusion: Results support the empirical and clinical relevance of the ICD-
11 model in capturing narcissistic pathology in addicted patients. Clinical
implications concerning assessment and treatment in addiction settings, and
certain limits regarding the Anankastia domain are discussed.
KEYWORDS
ICD-11, DSM-5 AMPD, narcissistic personality disorder, dissociality, personality
functioning, addiction
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Introduction
The search for connections between pathological
narcissism and addictions has a long tradition, especially
among psychoanalytically oriented authors. Wurmser (1), for
example, with reference to Kohut’s self-psychology, postulated
the basic psychological conditions leading to addiction.
These conditions include, in addition to psychosocial factors
and specific triggering conditions: (1) latent narcissistic
personality disorder (NPD) with internal contradictions
between idealized, grandiose ideas and the experience of oneself
and others (narcissistic conflict); (2) emotional disturbance,
accompanied by disillusionment, anger, a feeling of emptiness
or severe anxiety (narcissistic crisis). This challenging condition
motivates a person to search for a drug that should alleviate it.
The variable prevalence rates of co-morbid NPD and
substance use disorder (SUD)1in different settings (2,3)
imply a functional range in people given this diagnosis.
On the other hand, the method of establishing the NPD
diagnosis itself can significantly distort information about
the occurrence of manifestations of pathological narcissism
in the addicted population. To date, several comprehensive
reviews of pathological narcissism have been published
[e.g., (4–7)], which document the changing stages and
issues leading to difficulties in integrating scientific and
clinical knowledge of narcissistic disorder. Narcissism is
inconsistently defined and assessed across clinical psychology
and psychiatry thus, what is described, or empirically measured,
is often difficult to synthesize with each other. With an
attempt to synthesize theories of narcissism with research
findings, Pincus and Lukowitsky (8) proposed that pathological
narcissism is best conceptualized by a hierarchical model. In
their view, pathological narcissism is essentially characterized
by a combination of three psychodynamic phenomena:
dysfunctional self-regulation, dysfunctional emotion regulation,
and dysfunctional interpersonal relationships, which they
consider to be the basis of pathological narcissism and place
it on a continuum between the two basic prototypes: at one
end of the spectrum is the prototype of grandiose (arrogant,
indifferent) narcissism and at the other end is the prototype of
vulnerable (hypervigilant, exhausted) narcissism. Authors state
that both grandiose and vulnerable narcissism can manifest both
covertly and overtly.
Regarding a common etiology between
dissociality/psychopathy and substance abuse built upon
tendencies to novelty-seeking, impulsivity, and disinhibition
(9–11), a third prototype which includes narcissistic people
within the range of malignant narcissism, antisocial/dissocial
personality disorder, and psychopathy should be mentioned.
1 We use the term “SUD” when referring specifically to substance
addictions, while the term “addiction” is used when pointing to addictions
in general.
The characteristics of manipulativeness, exploitativeness,
and callousness can be considered general antagonistic
personality traits in this group of narcissistic personalities, most
closely shared between psychopathy and various narcissistic
dimensions [e.g., (12,13)]. This “classical” conceptualization
of psychopathy with narcissistic traits related to self-centered
antagonism takes on special importance also in connection
with the conceptualization of NPD and pathological narcissism
in the upcoming ICD-11 model for personality disorders
and the DSM-5 Alternative Model of Personality Disorders
(AMPD). However, recent research with the Trifurcated
Model of Narcissism (14) has demonstrated that, from the
perspective of current empirical conceptualizations, some
well-established psychopathy assessment instruments [e.g., the
Triarchic Psychopathy Measure (TriPM)] may not adequately
capture narcissistic traits relative to agentic extraversion, i.e.,
the second major component related to grandiose narcissism
(alongside self-centered antagonism) (15). On the other hand,
another study (16) in relation to the TriPM demonstrated a
significant overlap of its Boldness domain with the domains of
low Neuroticism and high Extraversion according to the general
and pathological five-factor model of psychopathology, which
is adopted in AMPD and to a large extent also in the ICD-11
model of maladaptive personality traits.
Although both the ICD-11 classification of personality
disorders and the AMPD work with the overall impairment
in self/other functioning and trait domains qualifiers that
contribute to the individual expression of personality
disorder (i.e., Negative Affectivity, Detachment, Disinhibition,
Dissociality/Antagonism, Anankastia, and Psychoticism2) (17),
the two models differ significantly in the way they operationalize
narcissistic psychopathology. While hybrid AMPD combines
a dimensional approach with the maintenance of a categorical
diagnosis of NPD (18), the ICD-11 model remains purely
dimensional (19). Even though, from the perspective of
personality traits, NPD determined in AMPD based on
grandiosity and attention seeking (i.e., both facets of the
Antagonism domain) may be advantageous for the clinician in
terms of more straightforward decision making, the diagnosis
is relying rather on overt and one-sided determinants of
grandiosity while the vulnerable features are not sufficiently
captured (20,21). The emphasis on self-centeredness as
an essential feature of narcissistic psychopathology is also
preserved in the ICD-11 model, which considers Dissociality
as a core trait domain, overarching all forms of pathological
narcissism (22). As the Dissociality trait domain qualifier
may not appear very specific for narcissism because it would
also characterize dissocial PD and psychopathy, according to
Bach et al. (23) it seems reasonable to combine Dissociality
with Anankastia domain when describing the grandiose
2 The Anankastia domain is only part of the ICD-11 model whereas the
Psychoticism domain is only part of the AMPD.
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narcissism prototype and with Negative Affectivity domain
when describing the vulnerable narcissism prototype.
If we consider the latter distinction based on how an
individual perceives and processes external feedback, some
parallel might be found with the reward sensitivity pathway
hypothesis predisposing NPD patients to substance abuse
based on dopaminergic/opioidergic hyperreactivity (24,25).
Moreover, Salazar et al. (26) in relation to the dopaminergic
effect in SUD patients, have recently proposed lack of empathy
and perceptions of invulnerability (i.e., common features of
self/other maladaptive functioning in SUDs) as mechanisms of
self-esteem regulation by means of self-inducing a “narcissistic
state.” From this perspective some individuals with SUDs
might engage in taking drugs to boost their inherent feeling
of superiority over others. Thus, the general assumption about
the low self-esteem of SUD patients becomes questionable.
Taken together, all these findings support the need for thorough
evaluation of narcissistic traits and their interpretation in the
context of overall personality functioning when the issue of
NPD and pathological narcissism in SUDs is in question.
Moreover, there is evidence that knowledge about the patient’s
personality might help to improve the working alliance and
prevent premature dropout or relapse, more frequent in SUD
patients with comorbid Cluster B PDs (27–29).
Considering extensive comorbidity within PD types based
on the traditional categorical approach (30), as well as the
recommendation of the DSM-5 to separate narcissistic traits
from symptoms that may develop in connection with the
continued use of addictive substances (18), there is a need
for diagnostic tools that allow a comprehensive and reliable
assessment of the manifestations of pathological narcissism in
addiction clients at different stages of the treatment process. It
was proved that a common factor underlying PDs accounts for
much of the comorbidity between Axis II personality disorders
and substance dependence, whereas residual Cluster B factor
was more highly related to the substance dependence diagnoses
than was the General PD factor (31). These findings to some
extent correspond with the results of Creswell et al. (32), who
proved the incremental validity of the AMPD Antagonism
and Disinhibition domains as assessed by the Personality
Inventory for DSM-5 (PID-5) (33) in predicting alcohol
problems above and beyond general personality dysfunction. On
the other hand, Papamalis (34) recently highlighted the role of
general personality dysfunction by pointing to certain adaptive
mechanisms of personality functioning such as self-control,
social concordance, and stable self-image as key predictors
of addiction treatment completion. In addition, low level
of the social concordance domain indicating “the ability to
value someone’s identity, withhold aggressive impulses toward
others and work together with others” remained one of the
most significant predictors of dropout. As these antagonistic
features associated with low agreeableness generally describe
disagreeable, distrustful, suspicious, oppositional, manipulative,
and/or arrogant individuals, who often lack insight into the
maladaptivity of their traits (35) a direct connection with
manifestations of pathological narcissism can be considered.
The issue of gender differences is also a current topic of
pathological narcissism research. Green et al. (36) in a recent
review pointed out the shortcomings of the hitherto prevailing
way of evaluating narcissistic pathology, which primarily focuses
on grandiose aspects that closely resemble prevailing masculine
norms. A gender imbalanced approach to the assessment
of narcissistic psychopathology may thus lead to the fact
that manifestations of pathological narcissism in women are
underdiagnosed, which can be manifested by shyness, shame,
hypersensitivity, and low self-esteem, i.e., components typical of
the vulnerable narcissistic prototype, rather than the aggressive
self-assertion typical of the grandiose prototype (5).
Despite the obvious evidence of the link between
pathological narcissism and SUDs, as well as evidence of
the clinical utility and validity of NPD (37), a limited number
of studies can be found in the current literature that deal with
the issue of narcissism in patients with addictions from the
perspective of dimensional models for PDs. This study seeks to
fill a research gap regarding the extent to which self-reported
personality pathology in addicted patients can be attributed
to traits of pathological narcissism or NPD. Due to the close
overlap between the ICD-11 PD model and AMPD, algorithms
to evaluate the five trait domains of the proposed ICD-11 based
on PID-5 have been recently proposed (38,39). Additionally,
newly developed modified version of the Personality Inventory
for DSM-5–Brief Form Plus (PID5BF+M) (40), which has
demonstrated satisfactory psychometric properties both as an
instrument extracted from the 220-item version of the PID-5
and as a stand-alone measure (41), allows for the parallel
assessment of maladaptive traits across both models. Similarly,
from the perspective of the overall personality functioning, the
Level of Personality Functioning Scale-Self-Report (LPFS-SR)
(42) proved its validity in assessing general personality severity
within the ICD-11 model above and beyond AMPD for which
it was primarily designed (43,44).
Based on the previous knowledge about the connection
between narcissistic psychopathology and SUDs in relation to
general personality dysfunction and dimensional personality
traits (e.g., 31, 32, 33, 34), the main goal of the present study
was to clarify to what extent the ICD-11 model for PDs
affects narcissistic phenomena in relation to both prototypes
of pathological narcissism, i.e., grandiose, and vulnerable.
In this regard, we hypothesized that the general personality
functioning impairment based on the LPFS-SR would cover
most manifestations of pathological narcissism. In relation to
the domains of personality traits based on the PID5BF+M,
we assumed the confirmation of the relation of the domains
Dissociality and Anankastia to the grandiose type of narcissism
and the domains of Dissociality and Negative Affectivity in
relation to the vulnerable type of narcissism, as postulated by
Bach et al. (23). Moreover, it is hoped that findings will enlarge
the current state of knowledge about the application of the
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new model in terms of discrimination capacity, convergent
validity, and its specificity toward the gender and the type
of addiction. These findings might potentially contribute to
the further development of the ICD-11 model and its clinical
usability in this specific clientele.
Materials and methods
Samples and procedures
Two samples were used in this study: a clinical sample
of SUD patients (Sample 1) and a control sample of general
population volunteers (Sample 2). Age over 18 and the ability
to read fluently in the Czech language were the inclusion
criteria in both samples; the diagnosis of addiction was
the inclusion criterion in the clinical sample; the exclusion
criteria in the clinical sample were the presence of acute
psychotic symptoms, current intoxication or organic brain
disorders accompanied by relevant cognitive impairment.
Participation in the study was voluntary and anonymous for
all respondents, and all participants were asked to give their
informed consent to participate in the study, which they had
the opportunity to withdraw at any time without stating the
reason. Participants were not rewarded for their participation
in the study; however, if they were interested in feedback, they
could provide us with their email address, which was held
apart from anonymously analyzed data. Trained administrators
conducted the data collection. The Ethics Committee of the
General University Hospital in Prague approved the study
protocol and the informed consent form. The total number of
(n= 988) respondents was included in the study, with certain
specifics in relation to the analyses performed (see Plan of
analysis for details).
Sample 1 (n= 421) consisted of patients with addiction
from seven facilities providing the specialized higher threshold
addiction treatment across the Czechia. To cover the widest
possible spectrum, institutions providing outpatient and
inpatient hospital care, as well as therapeutic communities, were
approached for cooperation. On the other hand, we excluded
lower threshold services, such as harm reduction interventions
and opioid substitution programs or detoxification units,
regarding the risk of data distortion due to acute intoxication
or low willingness of patients to cooperate. The diagnosis of
addiction was based on a standard clinical interview according
to the ICD-10/DSM-IV criteria, conducted by experienced
psychiatrists. Additional information about the individual
history of substance abuse or gambling were extracted from the
demographic questionnaire. The representation of respondents
by type of addiction was as follows: alcohol (n= 314, 74.6%);
illicit drugs (n= 235, 55.8%); prescribed medication (n= 138,
32.8%); gambling (n= 64, 15.2%).3The number of participants
according to gender was disproportionate: males (n= 290,
68.9%) prevailed over females (n= 129, 30.6%), two respondents
did not indicate their gender (0.5%). Age range was 18–73 years
(M= 39.3, SD = 10.9). The distribution of the highest
attained education was as follows: primary (elementary school)
education 24.8%; secondary (high school) education 62.7%;
and university education 12.5%. The patients were enrolled in
the study in collaboration with the Department of Addictology
(General University Hospital in Prague), psychiatric hospitals
in ˇ
Cervený Dv˚
ur, Dobˇ
rany, Prague-Bohnice, Havlíˇ
ck˚
uv Brod,
and Horní Beˇ
rkovice, and five therapeutic communities covered
by the psychiatric hospital in Bílá Voda.
Sample 2 (n= 567) consisted of university students from
various fields of study, working volunteers and pensioners.
Recruitment was carried out using convenience sampling.
Additional information about the individual history of
substance abuse or gambling were extracted from the
demographic questionnaire. The representation of respondents
by type of addiction was as follows: alcohol (n= 45, 6.7%);
illicit drugs (n= 52, 7.7%); prescribed medication (n= 32,
4.7%); gambling (n= 2, 0.3%). The number of participants
according to gender was again disproportionate: females
(n= 370, 65.2%) prevailed over males (n= 192, 33.9%) five
respondents did not indicate their gender (0.9%). Age range
was 18–75 years (M= 32.9, SD = 12.2). The distribution of the
highest attained education was as follows: primary (elementary
school) education 11.9%; secondary (high school) education
49.0%; and university education 39.1%.
In the Sample 1, the data collection was conducted
either individually (in case of outpatients) or in a group
by the paper-and-pencil method during several appointments
in the aforementioned institutions. Suitable respondents were
included in the study following consultations with the heads of
the psychiatric departments, who also obtained their informed
consent and allocated a time slot in the daily program for
the administration of the test battery. The attending clinician
introduced the administrators to the respondents. In the Sample
2, volunteers were asked to complete the test individually using
the paper-and-pencil method. All respondents were asked to
carefully read the instructions before starting the test, while the
administrator was present to assist with technical queries.
Instruments
Personality Inventory for DSM-5–Brief Form
Plus Modified (PID5BF+M)
We used the self-report PID5BF+M to operationalize the
ICD-11 and DSM-5 domains of personality traits. The six
domains have been calculated based on the average scores of
3 Total higher than 100% due to polyvalent addiction.
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the three primary facets of each particular domain: Negative
Affectivity has been calculated from the average scores of the
facets of emotional lability, anxiousness, separation insecurity;
Detachment from the facets of withdrawal, anhedonia,
intimacy avoidance; Dissociality/Antagonism from the facets
of manipulativeness, deceitfulness, grandiosity; Disinhibition
from the facets of irresponsibility, impulsivity, distractibility;
Psychoticism from the facets of unusual beliefs and experiences,
eccentricity, perceptual dysregulation; and Anankastia from
the facets of perfectionism, rigidity, and orderliness. The
operationalization of the Anankastia domain in the PID5BF+M
is based on the extraction of the three subfacets of orderliness,
rigidity, and perfectionism from the PID-5 composite facet
rigid perfectionism, which corresponds to the originally
proposed 37-facet version of PID-5 (45). At the same time,
PID5BF+M omits the perseveration facet as the primary facet
of the Anankastia domain because perseveration was originally
intended to capture signs of Negative Affectivity (46). The
complete PID5BF+M thus consists of 18 facets assessed through
36 items (two items per facet), rated on a four-point Likert scale
ranging from 0 (“very untrue or often untrue”) to 3 (“very true
or often true”). For the purposes of this study, we employed the
PID5BF+M extracted from the 220-item version of PID-5, in
accordance with previous studies (40,47). In the present study,
the Cronbach’s alphas for 6 PID5BF+M domains ranged from
0.61 (Anankastia) to 0.77 (Dissociality/Antagonism), indicating
acceptable internal consistency given the small number of
comprising items.
Level of Personality Functioning
Scale-Self-Report (LPFS-SR)
To assess the overall level of impairment in personality
functioning we administered LPFS-SR, a comprehensive self-
report measure for assessing criterion A of the AMPD. Due
to the apparent similarity of the two models, the LPFS-SR
can also be used to assess a general PD severity according
to ICD-11 criteria (43,44). It features descriptions of five
different levels of impairment in the domains of Identity, Self-
Direction, Empathy, and Intimacy. It includes 80 items that
are rated on four-point Likert scale ranging from 1 (“totally
false, not at all true”) to 4 (“very true”). In the present
study, the Cronbach’s alpha for the LPFS-SR total score was
0.95. The Cronbach’s alphas for 4 LPFS-SR domains ranged
from 0.89 (Intimacy) to 0.98 (Identity), indicating excellent
internal consistency.
Triarchic Psychopathy Measure (TriPM)
TriPM is a 58-item self-report instrument consisting of three
scales: Meanness, Boldness, and Disinhibition. The measure
uses a four-point Likert scale ranging from T (“True”) to
F (“False”), requiring the respondents to rate the degree to
which each item applies to them. The tool was developed
by Patrick et al. (48), studies found evidence for very good
internal consistencies, good test–retest reliability, and strong
validity consistent with the triarchic model of psychopathy
(49). For purposes of the present study, TriPM was used as a
predictor of grandiose narcissism prototype. Although, unlike
other instruments (e.g., Pathological Narcissism Inventory),
it is not primarily a method designed to assess grandiose
narcissism, we preferred TriPM due to its availability in
Czech. The Cronbach’s alpha for the TriPM total score was
0.87. The Cronbach’s alphas for three TriPM domains ranged
from 0.84 (Meanness) to 0.87 (Boldness) indicating excellent
internal consistency.
Hypersensitive narcissism scale (HSNS)
HSNS is a 10-item self-report scale measuring a covert
aspect of narcissism (50). Each statement should be evaluated on
the five-point Likert scale ranging from 1 (“very uncharacteristic
or untrue, strongly disagree”) to 5 (“very characteristic or true,
strongly agree”). For purposes of the present study, HSNS
was used as a predictor of vulnerable narcissism prototype.
Like in the case of the TriPM above, we preferred HSNS to
assess vulnerable narcissism due to its availability in Czech. Its
Cronbach’s alpha was 0.70, indicating good internal consistency.
Sociodemographic questionnaire
In addition to all above-mentioned measures, basic
demographic data (age, gender, educational status,
and type of addiction) were collected by means of a
self-designed questionnaire.
Plan of analysis
To minimize dropouts, we evaluated each instrument
separately as part of data cleaning procedure. This means that,
e.g., an invalid protocol due to missing items in one of the
methods did not necessarily mean that the respondent was
excluded from the study, if his/her answers in the other methods
allowed for a valid evaluation based on the instrument manual.
Moreover, we used the PID-5 Response Inconsistency Scale
(PID-5-RIS) developed by Keeley et al. (51), which has proven
successful in detecting random responses in the original version
of PID-5 and has been verified by several recent studies (52–
54). In line with these studies, we excluded respondents with a
PID-5-RIS score ≥17.
The internal consistency of each scale in both samples was
estimated using Cronbach’s alpha. The majority of Cronbach’s
alphas were ≥0.70 (with three exceptions in relation to
the PID5BF+M Anankastia, Psychoticism, and Detachment
domains), so the data were considered mostly internally
consistent. In addition, for measurement invariance testing
between PID-5 and PID5BF+M, we used a chi-square difference
test, as well as relative differences in additional fit indices.
For absolute model fit, the cut-off values of CFI >0.90 and
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RMSEA <0.08 were considered, as well as 90% confidence
intervals of RMSEA.
As the data did not meet the conditions for the regression
model and the errors have a normal distribution, general linear
models using Ordinary Least-Squares regression were applied
to show the effect of TriPM and HSNS on LPFS-SR and
PID5BF+M capacity to capture narcissistic psychopathology
first in Sample 1 and subsequently in Sample 2.
The Shapiro–Wilk test was used to test the data distribution.
As the data were predominantly not normally distributed,
non-parametric tests were used. Scales TriPM, HSNS, LPFS-
SR, as well as PID5BF+M domains of Negative Affec-
tivity, Detachment, Dissociality/Antagonism, Disinhibition,
Psychoticism, and Anankastia were compared between Sample
1 and Sample 2 and between gender by Mann–Whitney Utest.
The addiction type specificity in Sample 1 toward the scales was
tested by Kruskal–Wallis Htest. All p-values were corrected for
multiple testing by the Bonferroni adjustment.
All tests and models were done in IBM SPSS
Statistics 25 (55).
Results
Measurement invariance
To test the invariance between the original 220-item PID-5
and modified PID5BF+, we estimated a five-domain AMPD trait
model in accordance with the five domains qualifiers defined
in ICD-11. Confirmatory factor analysis confirmed excellent fit
with the original, 220-item PID-5, χ2(120)= 532.5, p<0.001,
CFI = 0.921, RMSEA = 0.061, 90% RMSEA CI [0.056, 0.066].
Capacity to capture narcissistic
pathology
In the predictive part of our analyses, we employed TriPM
domains of Boldness, Disinhibition, and Meanness, as well
as HSNS total score as predictors of the narcissistic features
latently contained in LPFS-SR and domains of PID5BF+M. As
can be seen from Table 1, we obtained quite similar results
for both samples. In both samples, the largest proportion
(almost 50%) of variability based on HSNS and TriPM can be
significantly explained in LPFS-SR. In contrast, the variability of
the Anankastia domain in both samples cannot be significantly
explained by either HSNS or TriPM. In the case of the Negative
Affectivity domain, approximately 40% of the variability can
be explained in both samples by HSNS and TriPM, however,
the TriPM Meanness domain proved to be a significant
negative predictor only in Sample 2. Similarly, in the case
of the Detachment domain, while in Sample 2 the TriPM
Disinhibition domain emerged as a significant predictor, in
Sample 1 this relationship was not demonstrated. The predictive
capacity of the TriPM Disinhibition domain also proved weak
in the case of the Dissociality/Antagonism domain, but only
in Sample 1. Nevertheless, almost 40% of variability of the
Dissociality/Antagonism domain in Sample 1 can be still
explained by HSNS and TriPM. The TriPM Boldness domain
emerged as a statistically significant negative predictor of the
Disinhibition domain, but only in Sample 1, while the TriPM
Meanness domain emerged as a weak but significant predictor
of the Psychoticism domain only in Sample 2.
Discrimination capacity
As can be seen from Table 2, it was found that respondents
from Sample 1 scored significantly higher in all observed
scales at p<0.001, only in Anankastia at p<0.05. From
the perspective of gender, in Sample 1, differences were
found between TriPM (U= 12968.5; p<0.001) where men
scored significantly higher, HSNS (U= 15685.5; p<0.013)
where women scored significantly higher, and PID5BF+M
domain Negative Affectivity (U= 9439.0; p<0.001) where
women scored significantly higher. In Sample 2, significant
differences were found between TriPM (U= 23853.5; p<0.001)
where men scored significantly higher, HSNS (U= 29858.0;
p<0.012) where women scored significantly higher, and
PID5BF+M domains Negative Affectivity (U= 20090.5;
p<0.001) where women scored significantly higher, and
Dissociality/Antagonism (U= 25464.5; p<0.001) where men
scored significantly higher.
Convergent validity
The correlations between the scales in both samples
are shown in Table 3. In Sample 1, the significant
correlations ranged from very low r= 0.13 (Detachment–
Dissociality/Antagonism) to high r= 0.92 (LPFS-SR total
score–Identity4). In Sample 2, the significant correlations
ranged from very low r= 0.09 (TriPM total score–HSNS
total score) to high r= 0.92 (LPFS-SR total score–Identity).
Interestingly, despite numerous intercorrelations, none of
the variables in either sample correlated with the Anankastia
domain. There was also no correlation between the Negative
Affectivity domain–TriPM total score in any of the samples.
Although the differences in correlation coefficients between
the two samples were rather small, three exceptions were
noted. The samples differed in the correlations Detachment–
Dissociality/Antagonism; Detachment–TriPM total score;
and TriPM total score–HSNS total score, while in all cases
respondents in Sample 2 demonstrated more significant
correlations.
4 This correlation was verified to compare which of the LPFS-SR
subscales better represents its total score. In this sense, it can be
understood as a certain way of assessing the internal consistency of the
LPFS-SR.
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TABLE 1 Prediction of narcissistic features in LPFS-SR and PID5BF+M domains in both samples.
S1 (Intercept) HSNS total TriPM_BOL TriPM_DIS TriPM_MEAN R-squared
LPFS-SR Estimate 283.312*** 4.546*** −1.673*** 1.575*** 1.202*** 0.451
SE 2.476 0.474 0.289 0.253 0.323
NEF Estimate 1.231*** 0.034*** −0.025*** 0.019*** −0.002 0.398
SE 0.012 0.006 0.003 0.003 0.004
DET Estimate 0.921*** 0.018*** −0.024*** −0.001 0.017*** 0.224
SE 0.028 0.005 0.003 0.003 0.004
DISO/ANT Estimate 0.795*** 0.028*** 0.015*** 0.007*0.025*** 0.38
SE 0.028 0.005 0.003 0.003 0.004
DIS Estimate 1.222*** 0.018*** −0.011*** 0.031*** −0.002 0.434
SE 0.027 0.005 0.003 0.003 0.004
PSY Estimate 0.855*** 0.028*** 0.004 0.019*** 0.002 0.291
SE 0.028 0.005 0.003 0.003 0.004
ANA Estimate 1.053*** −0.006 0 0 0.005 0.008
SE 0.033 0.006 0.004 0.003 0.004
S2 (Intercept) HSNS total TriPM_BOL TriPM_DIS TriPM_MEAN R-squared
LPFS-SR Estimate 215.715*** 2.741*** −1.632*** 3.175*** 1.035*** 0.486
SE 1.665 0.362 0.229 0.329 0.31
NEF Estimate 0.772*** 0.038*** −0.014*** 0.028*** −0.014*** 0.391
SE 0.021 0.005 0.003 0.004 0.004
DET Estimate 0.521*** 0.015*** −0.013*** 0.011** 0.015*** 0.255
SE 0.018 0.004 0.002 0.004 0.003
DISO/ANT Estimate 0.463*** 0.015*** 0.011*** 0.016*** 0.022*** 0.343
SE 0.017 0.004 0.002 0.003 0.003
DIS Estimate 0.651*** 0.016*** −0.004 0.035*** 0 0.364
SE 0.017 0.004 0.002 0.003 0.003
PSY Estimate 0.448*** 0.018*** 0.004 0.021*** 0.007*0.26
SE 0.017 0.004 0.002 0.003 0.003
ANA Estimate 1.161*** 0.002 −0.001 0.002 −0.003 0.003
SE 0.025 0.005 0.003 0.005 0.005
S1 and S2, Sample 1 and Sample 2; NEF, Negative Affectivity; DET, Detachment; DISO/ANT, Dissociality/Antagonism; DIS, Disinhibition; PSY, Psychoticism; ANA, Anankastia;
TriPM_BOL, Boldness; TriPM_DIS, Disinhibition; TriPM_MEAN, Meanness. *p<0.05; **p<0.01; ***p<0.001.
TABLE 2 Discrimination capacity between samples.
TriPM HSNS LPFS_SR NEF DET DISO/ANT DIS PSY ANA
S1 Median 66 33 280 1.17 0.83 0.67 1.17 0.83 1
Mean 68.91 32.33 283.52 1.23 0.92 0.8 1.22 0.86 1.06
SD 22.65 5.73 68.21 0.71 0.59 0.66 0.66 0.62 0.61
S2 Median 47 28 203 0.67 0.5 0.33 0.5 0.33 1.17
Mean 48.84 28.43 215.55 0.77 0.52 0.46 0.65 0.44 1.16
SD 15.63 5.63 54.68 0.6 0.47 0.47 0.49 0.45 0.57
Mann–Whitney U 54922.5*** 71161.0*** 50962.5*** 56863.5*** 53899.5*** 62880.0*** 44723.5*** 53551.0*** 82267.5*
S1 and S2, Sample 1 and Sample 2; NEF,Negative Affectivity; DET, Detachment; DISO/ANT,Dissociality/Antagonism; DIS, Disinhibition; PSY, Psychoticism;ANA, Anankastia. *p<0.05;
***p<0.001.
The addiction type specificity
Based on the available data, we determined four groups of
patients according to the type of addiction within Sample 1.
The first group consisted of patients with mixed addiction to
alcohol and illicit drugs. The second group consisted of patients
addicted only to alcohol, the third patients addicted only to
illicit drugs, and the fourth gamblers and prescribed medication
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TABLE 3 Correlations between scales in both samples.
NEF DET DIS DISO/ANT PSY ANA LPFS-SR total Identity Self-direction Empathy Intimacy TriPM total HSNS total
NEF S1 −
S2 −
DET S1 0.32*** −
S2 0.38*** −
DIS S1 0.56*** 0.37*** −
S2 0.57*** 0.40*** −
DISO/ANT S1 0.28*** 0.13*0.31*** −
S2 0.27*** 0.44*** 0.40*** −
PSY S1 0.46*** 0.32*** 0.58*** 0.46*** −
S2 0.45*** 0.45*** 0.55*** 0.50*** −
ANA S1 −0.01 0.02 −0.01 0.00 0.02 −
S2 0.03 −0.03 0.04 −0.08 −0.04 −
LPFS-SR Total S1 0.62*** 0.49*** 0.59*** 0.34*** 0.53*** 0.03 −
S2 0.61*** 0.56*** 0.62*** 0.47*** 0.56*** 0.03 −
Identity S1 0.64*** 0.37*** 0.59*** 0.30*** 0.52*** 0.04 0.92*** −
S2 0.66*** 0.49*** 0.63*** 0.40*** 0.53*** 0.03 0.93*** −
Self-Direction S1 0.55*** 0.48*** 0.54*** 0.26*** 0.42*** 0.07 0.90*** 0.78*** −
S2 0.52*** 0.49*** 0.60*** 0.41*** 0.48*** 0.02 0.90*** 0.81*** −
Empathy S1 0.46*** 0.44*** 0.49*** 0.35*** 0.49*** 0.06 0.86*** 0.71*** 0.70*** −
S2 0.45*** 0.48*** 0.51*** 0.43*** 0.54*** −0.01 0.86*** 0.71*** 0.74*** −
Intimacy S1 0.53*** 0.49*** 0.48*** 0.32*** 0.48*** −0.05 0.87*** 0.69*** 0.68*** 0.72*** −
S2 0.51*** 0.55*** 0.41*** 0.45*** 0.47*** 0.03 0.88*** 0.73*** 0.69*** 0.74*** −
TriPM Total S1 0.07 0.02 0.34*** 0.57*** 0.39*** 0.06 0.26*** 0.23*** 0.20*** 0.24*** 0.27*** −
S2 −0.00 0.13** 0.26*** 0.49*** 0.32*** 0.00 0.30*** 0.24*** 0.28*** 0.33*** 0.26*** −
HSNS Total S1 0.47*** 0.30*** 0.39*** 0.28*** 0.38*** −0.05 0.55*** 0.56*** 0.41*** 0.48*** 0.47*** 0.09 −
S2 0.55*** 0.39*** 0.44*** 0.29*** 0.38*** 0.03 0.55*** 0.54*** 0.45*** 0.47*** 0.50*** 0.09*−
S1 and S2, Sample 1 and Sample 2; NEF, Negative Affectivity; DET, Detachment; DISO/ANT, Dissociality/Antagonism; DIS, Disinhibition; PSY, Psychoticism;ANA, Anankastia. *p<0.05; **p<0.01; ***p<0.001.
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abusers. In the case of TriPM, groups differed by addiction
type in all TriPM domains, i.e., Boldness (p= 0.019), Meanness
(p= 0.031), and Disinhibition (p= 0.006). In relation to the
HSNS, no difference was found between the groups with respect
to the type of addiction (all p-values >0.05). In the case of LPFS-
SR, the difference was noticeable only in the Self-Direction
domain (p= 0.036). The post-hoc test showed that only the third
and fourth groups differ, i.e., the “only drugs” group (M= 77.79)
and the “no alcohol/drugs” group (M= 64.13; p= 0.042). Finally,
no difference was found in any of the six PID5BF+M domains by
addiction type (all p-values >0.05).
Discussion
The current study primarily aimed to assess the capacity of
the ICD-11 model for PDs to capture the features of narcissistic
psychopathology in patients with addiction and the general
population volunteers. We employed self-reported LPFS-SR
and PID5BF+M as measurements of the general personality
impairment and trait domains qualifiers, respectively. Moreover,
we used TriPM and HSNS as measures of two types of
pathological narcissism (i.e., grandiose, and vulnerable) in
predicting the latent narcissistic features within the LPFS-
SR and six domains of the PID5BF+M. In addition, our
results contribute to the current state of knowledge on the
clinical utility of the new model in terms of its ability to
differentiate between clinical and non-clinical populations,
gender, and to some extent, addicted patients depending on the
type of addiction.
Despite the overlap between the DSM-5 AMPD and
the ICD-11 model for PDs, a necessary first step from the
perspective of personality trait qualifiers was the transposition of
the original 220-item PID-5 into PID5BF+M, allowing the ICD-
11 Anankastia qualifier to be evaluated. As the factor structure
and internal consistency of the PID5BF+M published in earlier
studies (40,41) were confirmed for both of our samples, it was
possible to consider this instrument as valid and reliable for our
further analyses.
With regard the main objective of the study, our findings
that almost 50% of LPFS-SR variability can be explained
based on HSNS and TriPM confirm the fact that the
core of the problem of pathological narcissism lies in a
disturbed relationship with self and others (6) and thus
underline the importance that the ICD-11 model for PDs
places on the evaluation of personality functioning (56).
On the other hand, related to the issue of SUDs, our
results are somewhat contrary to the hypothesis of Salazar
et al. (26) on the regulation of self-esteem by means
of self-inducing a “narcissistic state,” according to which
individuals take drugs to boost their inherent feeling of
superiority over others. Since the HSNS score in Sample
1 proved to be the main predictor of LPFS-SR variability,
it can be assumed that SUD patients in our study have
rather low self-esteem associated with inferiority features of
vulnerable narcissism. From the point of view of PID5BF+M,
the expected associations with the Negative Affectivity and
Dissociality/Antagonism domains were confirmed for both
samples in relation to narcissistic psychopathology (23),
although the latter domain was not confirmed as dominant.
From the perspective of trait qualifiers, the relatively high
capacity of the Disinhibition domain in capturing narcissistic
pathology, which is usually associated with borderline PD
rather than NPD, can be somewhat surprising. On the other
hand, Clarkin et al. (57) point to the fact that low level
borderlines are likely to have borderline PD with co-morbid
narcissistic, paranoid, and antisocial PD or traits. In terms
of anankastic traits, in contrast to previously postulated
conclusions about perfectionistic overcompensation and rule-
bound narcissistic dominance (58), no association between the
Anankastia domain and both external measures of narcissistic
psychopathology (i.e., HSNS and TriPM) was demonstrated
in our study. Our results rather confirm earlier findings
that NPD was present to a very low degree or absent
in individuals with OCD (2). Although anankastic features
can undisputable be found also in individuals with NPD,
from the perspective of object relations theory, narcissistic
disorders such as dissocial/antisocial PD, the syndrome of
malignant narcissism, or NPD per se may be conceptualized
along a continuum of rather extraverted pole of borderline
personality organization spectrum, based on the degree of
superego pathology, the intensity of projective defenses, and
the presence of ego-syntonic aggression (59). In contrast,
obsessive-compulsive PD is located within the introverted
pole of neurotic personality organization (60). In this regard,
our findings on the Anankastia domain can be interpreted
that, although links between anankastic manifestations and
manifestations of pathological narcissism may be observable at
the symptom level, there is no direct connection between the
two clinical phenomena in the context of deeper personality
functioning. Other observed differences in magnitudes of
statistical significance between the two samples (especially in
relation to TriPM domains) can be interpreted in context of the
greater sensitivity of the clinical sample in the detection of subtle
psychopathological phenomena.
Considering the previously confirmed capacity of the
original five domains of PID-5 to distinguish between
clinical and non-clinical populations (61), it is not surprising
that it was also confirmed in this study. Nevertheless, it
is interesting that the Anankastia domain was the only
one to show a lower statistical significance compared to
the other PID5BF+M domains and scales. Similar problem
was recently reported by Hemmati et al. (62). It can be
considered that the orderliness, rigidity, and perfectionism
facets may point to more desirable personality traits that
can be found in individuals from the general population to
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a similar extent as in addiction patients. In other words,
the Negative Affectivity, Detachment, Dissociality/Antagonism,
Disinhibition, and Psychoticism domains, as well as the LPFS-
SR, HSNS, and TriPM, may better address maladaptive variants
of personality features that can be predicted to manifest more
prominently in the clinical population.
From the perspective of gender differences, our results
somewhat contradict the conclusions of the meta-analysis by
Grijalva et al. (63), which showed that while men show more
often than women manifestations of grandiose narcissism with
signs of aggression and antagonism, in the case of vulnerable
narcissism, gender differences were not demonstrated. However,
the authors point out that these conclusions may be largely
conditioned by the lack of studies verifying the manifestations of
vulnerable narcissism in relation to gender. The predominance
of men in manifestations of grandiose narcissism based on the
TriPM was also evident in our study in both, the clinical and
non-clinical sample (in the case of a general population sample
in connection with the Dissociality/Antagonism domain).
However, vulnerable narcissism based on the HSNS showed
to be significant in both samples in women, in connection
with the Negative Affectivity domain. In this regard, our
results can be seen as further contribution to the empirical
discussion on the issue of gender specificity of vulnerable
narcissism in connection with five-factor models of personality.
Considering Negative Affectivity as the negative pole of
the Big Five trait of neuroticism (64), our findings are
in line not only with Pincus et al. (65), who postulated
the vulnerable narcissism as a negative affect-laden form of
narcissism that is positively associated with the Big Five trait
of neuroticism, but also with assumption about higher levels
of neuroticism (i.e., less emotional stability) among women
(66). Thus, it can be hypothesized that just as a higher level
of Dissociality/Antagonism can increase the level of grandiose
narcissism in men, so a higher level of Negative Affectivity
can increase the level of vulnerable narcissism in women.
However, this hypothesis requires further validation in both,
clinical and non-clinical samples. In line with the conclusion
of Green et al. (36) that gender may play a key factor that
partly determines specific psychopathological constellations,
our findings regarding the prevalence of vulnerable narcissistic
features among women shed light on the specifics of
addiction treatment in women. From a clinical perspective,
the question remains whether unified regimen treatments
based on discipline and order may not further increase the
feeling of inferiority and thus dependence on authority, rather
than promoting the growth of healthy female self-confidence
and independence.
In terms of convergent validity, our results in general
confirm the hypothesis of a strong common factor of PD
severity, which might be scaled along a single latent continuum
by measures specifically developed or adapted to capture the
personality psychopathology within the ICD-11 model for
PDs, i.e., PID5BF+M and LPFS-SR (67). From the perspective
of the ICD-11 model, however, the Anankastia domain
deserves special attention, while did not show any significant
correlations with the other PID5BF+M domains or scales.
Given that Anankastia in the ICD-11 model is intended
to serve primarily as a qualifier of anankastic/obsessive-
compulsive PD (23), which simultaneously exhibits the least
impairment of personality functioning in relation to work,
social relationships, and leisure activities when compared
to other ICD-10 PDs (68), it can be hypothesized, that
unlike the other ICD-11 qualifiers of personality traits,
Anankastia is the only one that does not contain information
related to the general personality structure adopted from
the Five-Factor Model of personality (35). As such, it can
contribute unique information about the patient’s maladaptive
manifestations in relation to perfectionism, rigidity, and
orderliness only if it is interpreted in the context of a
separately assessed level of impairment in the overall personality
functioning of the given individual (69). The absence of
a significant correlation between the Negative Affectivity
domain and the TriPM total score in both samples can be
seen as expected given that the TriPM is a tool primarily
intended for the evaluation of externalizing features of
personality psychopathology (48), while Negative Affectivity
affects symptomatic manifestations from the area of the
internalizing spectrum (70). Differences in the magnitude of
some correlations between Sample 1 and Sample 2 can be again
attributed to the greater sensitivity of the clinical sample in
the detection of subtle psychopathological phenomena. As all
three aforementioned differences address correlations between
opposing constructs (see Section “Results”), none of them
appear to be clinically significant.
Finally, regarding addiction type specificity, our results
pointing to differences between groups according to the type
of addiction in TriPM domains can be interpreted from
the point of view of the different degree of externalizing
behavior in patients with SUD. This assumption is somewhat
consistent with the conclusions of Few et al. (71) on the
influence of externalizing behavior on variability in alcohol,
drug use and antisocial behavior. Since the groups of alcohol-
dependent and polysubstance-dependent patients were the most
represented, our results in relation to TriPM underline the
importance of clinical evaluation of externalizing behavior
within a standard addiction setting. Adopting an object relations
model perspective of narcissism and psychopathy (72), a
thorough examination of the degrees of deficits in moral
functioning appears to be a beneficial procedure for capturing
the level of superego pathology that may have a significant
impact on treatment outcome and relapse prevention. It can
be hypothesized that as the degree of severity of superego
dysfunction increases, the patient’s willingness to adhere
to abstinence and recommended treatment procedures will
decrease if there is no immediate external personal gain. This
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assumption could be confirmed also in the case of illicit drug
users, although it requires further verification in better balanced
samples of addicted patients according to the substance used.
Regarding the difference between groups noted in relation to
LPFS-SR, because the group without alcohol/drugs addiction
consisted largely of gamblers, the difference between the pure
drug users’ group and no alcohol/drugs addiction group in
LPFS-SR Self-Direction domain may be attributed to individual
differences in features of impulsivity and compulsivity (73)
rather than more general differences in the ability to set
and adhere to short-term and long-term goals. However, the
possibility of a statistical artifact cannot be excluded due to the
low number of pure drug users in our clinical sample (n= 14).
The results of our study contribute to the current state of
knowledge in several ways. First, we confirmed the capacity
of the LPFS-SR and most of the PID5BF+M domains in
detecting features of vulnerable/hypersensitive and grandiose
narcissism; second we have confirmed the ability of the
ICD-11 model for PDs to differentiate between clinical and
non-clinical populations based on self-reported LPFS-SR and
PID5BF+M; third, our findings support the gender specificity
toward the two prototypes of pathological narcissism; fourth,
we highlighted the interconnections between both crucial parts
of the ICD-11 model, i.e., the overall level of impairment in
personality functioning and PD trait qualifiers with exception
for Anankastia domain; and finally fifth, our findings illuminate
some personality specifics between the subgroups of addicted
patients in relation to the type of addiction. However, our
findings should be considered in light of certain limitations
that may inspire future research. We consider the method
of data collection itself to be a significant limitation of the
study. The battery of questionnaires was very comprehensive
and made great demands on the participants’ time and ability
to concentrate. In this regard, the so-called non-response bias
could have occurred in some cases, which according to Sedgwick
(74) is the most common limit in questionnaire surveys.
Respondents may miss the question, or miss it on purpose,
and the reasons may be socio-cultural, or in behavior and
attitudes. Although we subjected the data to a thorough cleaning
procedure, it can’t be ruled out that a different order of the
questionnaires or their distribution into two shorter sets could
have a positive effect on their quality, especially regarding the
number of missing items in some scales. Another limitation
may be our focus on addicted patients from high-threshold
services. This choice was deliberate regarding the high risk of
dropout and acute intoxication in low-threshold clientele. On
the other hand, we are aware that by excluding this large group
of patients with addiction, there was an impoverishment of data
on psychopathological phenomena that can have a significant
influence in relation to narcissism. Clinical practice confirms
that low-threshold clientele shows a higher degree of personality
pathology and criminal behavior. Thus, future research could
significantly enrich our findings by including these patients.
From the perspective of expanding the clinical implications of
our findings into addiction settings, future research should focus
on more detailed analyses of differences in the type of addiction
with an emphasis on a more balanced groups of addicted
patients. Finally, reliance on self-report data on pathological
narcissism and NPD may be a limitation. Both grandiosity
and vulnerability can hinder accurate self-assessment and affect
the accuracy of assessment of individual personality pathology.
From this perspective, supplementing the assessment with, for
example, the Structured Interview of Personality Organization-
Revised (STIPO-R) (75), including an index for the assessment
of pathological narcissism, seems to be a suitable solution.
Data availability statement
The raw data supporting the conclusions of this article will
be made available by the authors, without undue reservation.
Ethics statement
The studies involving human participants were reviewed
and approved by Ethics Committee of the General University
Hospital in Prague Na Bojišti 1, 128 08 Prague 2. The
patients/participants provided their written informed consent to
participate in this study.
Author contributions
KDR drafted the manuscript, supported the data analyses,
and was responsible for its final version. LS was responsible
for data collection. TSZ wrote parts of the introduction and
discussion and critically revised the first draft. All authors
contributed to the article and approved the submitted version.
Funding
The Article Processing Charge was funded by the
Open Access Fund of the General University Hospital in
Prague, Czechia. This publication has been supported by the
Institutional Support Programme Cooperation, research area
HEAS and was written under Specific University Research,
Grant No. 260500.
Conflict of interest
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
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References
1. Wurmser L. The role of superego conflicts in substance abuse and their
treatment. Int J Psychoanal Psychother. (1984/1985) 10:227–58.
2. Ronningstam E. Pathological narcissism and narcissistic personality disorder
in Axis I disorders. Harv Rev Psychiatry. (1996) 3:326–40. doi: 10.3109/
10673229609017201
3. Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM,
et al. Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic
personality disorder: results from the wave 2 national epidemiologic survey on
alcohol and related conditions. J Clin Psychiatry. (2008) 69:1033–45. doi: 10.4088/
jcp.v69n0701
4. Levy KN, Reynoso JS, Wasserman RH, Clarkin JF. Narcissistic personality
disorder. In: O’Donohue W, Fowler KA, Lilienfeld SO editors. Personality
Disorders: Toward the DSM-V. Thousand Oaks, CA: Sage Publications, Inc (2007).
p. 233–77. doi: 10.4135/9781483328980.n9
5. Cain NM, Pincus AL, Ansell EB. Narcissism at the crossroads: phenotypic
description of pathological narcissism across clinical theory, social/personality
psychology, and psychiatric diagnosis. Clin Psychol Rev. (2008) 28:638–56. doi:
10.1016/j.cpr.2007.09.006
6. Ronningstam E. Narcissistic personality disorder: facing DSM-V. Psychiatr
Ann. (2009) 39:111–21. doi: 10.3928/00485713-20090301- 09
7. Alarcón RD, Sarabia S. Debates on the narcissism conundrum: trait, domain,
dimension, type, or disorder? J Nerv Ment Dis. (2012) 200:16–25. doi: 10.1097/
NMD.0b013e31823e6795
8. Pincus AL, Lukowitsky MR. Pathological narcissism and narcissistic
personality disorder. Annu Rev Clin Psychol. (2010) 6:421–46. doi: 10.1146/
annurev.clinpsy.121208.131215
9. Zimmerman M, Coryell W. DSM-III personality disorder diagnoses in a
nonpatient sample. Demographic correlates and comorbidity. Arch Gen Psychiatry.
(1989) 46:682–9. doi: 10.1001/archpsyc.1989.01810080012002
10. Krueger RF, Hicks BM, Patrick CJ, Carlson SR, Iacono WG, McGue M.
Etiologic connections among substance dependence, antisocial behavior, and
personality: modeling the externalizing spectrum. J Abnorm Psychol. (2002)
111:411–24. doi: 10.1037/0021-843X.111.3.411
11. Patrick CJ, Hicks BM, Krueger RF, Lang AR. Relations between psychopathy
facets and externalizing in a criminal offender sample. J Pers Disord. (2005)
19:339–56. doi: 10.1521/pedi.2005.19.4.339
12. Kernberg OF. Factors in the psychoanalytic treatment of narcissistic
personalities. J Am Psychoanal Assoc. (1970) 18:51–85. doi: 10.1177/
000306517001800103
13. Hare RD. A research scale for the assessment of psychopathy in criminal
populations. Pers Individ Differ. (1980) 1:111–9. doi: 10.1016/0191-8869(80)9
0028-8
14. Weiss B, Campbell WK, Lynam DR, Miller JD. A trifurcated model of
narcissism: on the pivotal role of trait antagonism. In: Miller JD, Lynam DR editors.
The Handbook of Antagonism: Conceptualizations, Assessment, Consequences, and
Treatment of the Low End of Agreeableness. Cambridge, MA: Elsevier Academic
Press (2019). p. 221–35. doi: 10.1016/B978-0- 12-814627-9.00015- 3
15. Weiss B, Sleep CE, Lynam DR, Miller JD. Evaluating the instantiation of
narcissism components in contemporary measures of psychopathy. Assessment.
(2021) 28:15–28. doi: 10.1177/1073191120916797
16. Hyatt CS, Crowe ML, Lynam DR, Miller JD. Components of the
triarchic model of psychopathy and the five-factor model domains share largely
overlapping nomological networks. Assessment. (2020) 27:72–88. doi: 10.1177/
1073191119860903
17. Bach B, First MB. Application of the ICD-11 classification of personality
disorders. BMC Psychiatry. (2018) 18:351. doi: 10.1186/s12888-018-1908- 3
18. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association (2013).
doi: 10.1176/appi.books.9780890425596
19. World Health Organisation. ICD-11 Clinical Descriptions and Diagnostic
Guidelines for Mental and Behavioural Disorders. Geneva: World Health
Organisation (2022).
20. Miller JD, Gentile B, Wilson L, Campbell WK. Grandiose and vulnerable
narcissism and the DSM-5 pathological personality trait model. J Pers Assess. (2013)
95:284–90. doi: 10.1080/00223891.2012.685907
21. Wright AG, Pincus AL, Thomas KM, Hopwood CJ, Markon KE, Krueger
RF. Conceptions of narcissism and the DSM-5 pathological personality traits.
Assessment. (2013) 20:339–52. doi: 10.1177/1073191113486692
22. Bach B, Sellbom M, Skjernov M, Simonsen E. ICD-11 and DSM-5 personality
trait domains capture categorical personality disorders: finding a common ground.
Aust N Z J Psychiatry. (2018) 52:425–34. doi: 10.1177/0004867417727867
23. Bach B, Kramer U, Doering S, di Giacomo E, Hutsebaut J, Kaera A, et al.
The ICD-11 classification of personality disorders: a European perspective on
challenges and opportunities. Borderline Personal Disord Emot Dysregul. (2022)
9:12. doi: 10.1186/s40479-022- 00182-0
24. Verheul R. Co-morbidity of personality disorders in individuals with
substance use disorders. Eur Psychiatry. (2001) 16:274–82. doi: 10.1016/s0924-
9338(01)00578-8
25. Verheul R, van den Brink W. Causal pathways between substance use
disorders and personality pathology. Aust Psychol. (2005) 40:127–36. doi: 10.1080/
00050060500094613
26. Salazar J, Page B, Ripoll C. Features, state and context of narcissism in drug
misuse. Subst Use Misuse. (2021) 56:11–24. doi: 10.1080/10826084.2020.1833923
27. Gerstley L, McLellan AT, Alterman AI, Woody GE, Luborsky L, Prout M.
Ability to form an alliance with the therapist: a possible marker of prognosis for
patients with antisocial personality disorder. Am J Psychiatry. (1989) 146:508–12.
doi: 10.1176/ajp.146.4.508
28. Verheul R, van den Brink W, Hartgers C. Personality disorders predict relapse
in alcoholic patients. Addict Behav. (1998) 23:869–82. doi: 10.1016/s0306-4603(98)
00065-3
29. Ross S, Dermatis H, Levounis P, Galanter M. A comparison between dually
diagnosed inpatients with and without Axis II comorbidity and the relationship to
treatment outcome. Am J Drug Alcohol Abuse. (2003) 29:263–79. doi: 10.1081/ada-
120020511
30. Widiger TA, Livesley WJ, Clark LA. An integrative dimensional classification
of personality disorder. Psychol Assess. (2009) 21:243–55. doi: 10.1037/a0016606
31. Jahng S, Trull TJ, Wood PK, Tragesser SL, Tomko R, Grant JD, et al.
Distinguishing general and specific personality disorder features and implications
for substance dependence comorbidity. J Abnorm Psychol. (2011) 120:656–69. doi:
10.1037/a0023539
32. Creswell KG, Bachrach RL, Wright AG, Pinto A, Ansell E. Predicting
problematic alcohol use with the DSM-5 alternative model of personality
pathology. Personal Disord. (2016) 7:103–11. doi: 10.1037/per0000131
33. Krueger RF, Derringer J, Markon KE, Watson D, Skodol AE. Initial
construction of a maladaptive personality trait model and inventory for DSM-5.
Psychol Med. (2012) 42:1879–90. doi: 10.1017/S0033291711002674
34. Papamalis FE. Examining the relationship of personality functioning and
treatment completion in substance misuse treatment. Subst Abuse. (2020)
14:1178221820951777. doi: 10.1177/1178221820951777
35. Widiger TA, Presnall JR. Clinical application of the five-factor model. J Pers.
(2013) 81:515–27. doi: 10.1111/jopy.12004
36. Green A, MacLean R, Charles K. Female narcissism: assessment, aetiology,
and behavioural manifestations. Psychol Rep. (2022) 125:2833–64. doi: 10.1177/
00332941211027322
37. Pincus AL. Some comments on nomology, diagnostic process, and
narcissistic personality disorder in the DSM-5 proposal for personality and
personality disorders. Personal Disord. (2011) 2:41–53. doi: 10.1037/a0021191
Frontiers in Psychiatry 12 frontiersin.org

fpsyt-13-1041480 November 23, 2022 Time: 7:29 # 13
Riegel et al. 10.3389/fpsyt.2022.1041480
38. Bach B, Sellbom M, Kongerslev M, Simonsen E, Krueger RF, Mulder R.
Deriving ICD-11 personality disorder domains from DSM-5 traits: initial attempt
to harmonize two diagnostic systems. Acta Psychiatr Scand. (2017) 136:108–17.
doi: 10.1111/acps.12748
39. Sellbom M, Solomon-Krakus S, Bach B, Bagby RM. Validation of personality
inventory for DSM-5 (PID-5) algorithms to assess ICD-11 personality trait domains
in a psychiatric sample. Psychol Assess. (2020) 32:40–9. doi: 10.1037/pas0000746
40. Bach B, Kerber A, Aluja A, Bastiaens T, Keeley JW, Claes L, et al. International
assessment of DSM-5 and ICD-11 personality disorder traits: toward a common
nosology in DSM-5.1. Psychopathology. (2020) 53:179–88. doi: 10.1159/000507589
41. Riegel KD, Ksinan AJ, Schlosserova L. Psychometric properties of the
independent 36-item PID5BF+M for ICD-11 in the Czech-speaking community
sample. Front Psychiatry. (2021) 12:643270. doi: 10.3389/fpsyt.2021.643270
42. Morey LC. Development and initial evaluation of a self-report form of the
DSM-5 level of personality functioning scale. Psychol Assess. (2017) 29:1302–8.
doi: 10.1037/pas0000450
43. Nazari A, Huprich SK, Hemmati A, Rezaei F. The construct validity of
the ICD-11 severity of personality dysfunction under scrutiny of object-relations
theory. Front Psychiatry. (2021) 12:648427. doi: 10.3389/fpsyt.2021.648427
44. Riegel KD, Konecna J, Matoulek M, Rosova L. Implementation of the DSM-5
and ICD-11 dimensional models of maladaptive personality traits into pre-bariatric
assessment. Front Psychol. (2022) 12:814421. doi: 10.3389/fpsyg.2021.814421
45. Bach B, Maples-Keller JL, Bo S, Simonsen E. The alternative DSM-5
personality disorder traits criterion: a comparative examination of three self-report
forms in a Danish population. Personal Disord. (2016) 7:124–35. doi: 10.1037/
per0000162
46. Watters CA, Bagby RM. A meta-analysis of the five-factor internal structure
of the personality inventory for DSM-5. Psychol Assess. (2018) 30:1255–60. doi:
10.1037/pas0000605
47. Kerber A, Schultze M, Müller S, Rühling RM, Wright AGC, Spitzer C, et al.
Development of a short and ICD-11 compatible measure for DSM-5 maladaptive
personality traits using ant colony optimization algorithms. Assessment. (2022)
29:467–87. doi: 10.1177/1073191120971848
48. Patrick CJ, Fowles DC, Krueger RF. Triarchic conceptualization of
psychopathy: developmental origins of disinhibition, boldness, and meanness. Dev
Psychopathol. (2009) 21:913–38. doi: 10.1017/S0954579409000492
49. Blagov PS, Patrick CJ, Oost KM, Goodman JA, Pugh AT. Triarchic
psychopathy measure: validity in relation to normal-range traits, personality
pathology, and psychological adjustment. J Pers Disord. (2016) 30:71–81. doi: 10.
1521/pedi_2015_29_182
50. Hendin HM, C heek JM. Assessinghypersensitive narcissism: a reexamination
of Murray’snarcism scale. J Res Pers. (1997) 31:588–99. doi: 10.1006/jrpe.1997.2204
51. Keeley JW, Webb C, Peterson D, Roussin L, Flanagan EH. Development of a
response inconsistency scale for the personality inventory for DSM-5. J Pers Assess.
(2016) 98:351–9. doi: 10.1080/00223891.2016.1158719
52. Somma A, Borroni S, Kelley SE, Edens JF, Fossati A. Further evidence for the
validity of a response inconsistency scale for the personality inventory for DSM-5 in
Italian community-dwelling adolescents, community-dwelling adults, and clinical
adults. Psychol Assess. (2018) 30:929–40. doi: 10.1037/pas0000547
53. Bagby RM, Sellbom M. The validity and clinical utility of the personality
inventory for DSM-5 response inconsistency scale. J Pers Assess. (2018) 100:398–
405. doi: 10.1080/00223891.2017.1420659
54. Lowmaster SE, Hartman MJ, Zimmermann J, Baldock ZC, Kurtz JE. Further
validation of the response inconsistency scale for the personality inventory
for DSM-5. J Pers Assess. (2020) 102:743–50. doi: 10.1080/00223891.2019.167
4320
55. IBM Corp. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM
Corp (2017).
56. Blüml V, Doering S. ICD-11 personality disorders: a psychodynamic
perspective on personality functioning. Front Psychiatry. (2021) 12:654026. doi:
10.3389/fpsyt.2021.654026
57. Clarkin JF, Lenzenweger MF, Yeomans F, Levy KN, Kernberg OF. An object
relations model of borderline pathology. J Pers Disord. (2007) 21:474–99. doi:
10.1521/pedi.2007.21.5.474
58. Fjermestad-Noll J, Ronningstam E, Bach BS, Rosenbaum B, Simonsen E.
Perfectionism, shame, and aggression in depressive patients with narcissistic
personality disorder. J Pers Disord. (2020) 34:25–41. doi: 10.1521/pedi.2020.34.
supp.25
59. Koenigsberg HW, Kernberg OF, Stone MH, Appelbaum AH, Yeomans FE,
Diamond D. Borderline Patients: Extending the Limits of Treatability. New York,
NY: Basic Books (2000).
60. Kernberg OF. Severe Personality Disorders: Psychotherapeutic Strategies. New
Haven, CT: Yale University Press (1984).
61. Riegel KD, Preiss M, Ksinan AJ, Michalec J, Samankova D, Harsa P.
Psychometric properties of the Czech version of the personality inventory for
DSM-5: internal consistency, validity, and discrimination capacity of the measure.
Czechoslovak Psychol. (2017) 61:128–43.
62. Hemmati A, R ahmani F, Bach B. The ICD-11 personality disorder trait model
fits the Kurdish population better than the DSM-5 trait model. Front Psychiatry.
(2021) 12:635813. doi: 10.3389/fpsyt.2021.635813
63. Grijalva E, Newman DA, Tay L, Donnellan MB, Harms PD, Robins RW,
et al. Gender differences in narcissism: a meta-analytic review. Psychol Bull. (2015)
141:261–310. doi: 10.1037/a0038231
64. De Fruyt F, De Clercq B, De Bolle M, Wille B,Markon K, Krueger RF. General
and maladaptive traits in a five-factor framework for DSM-5 in a university student
sample. Assessment. (2013) 20:295–307. doi: 10.1177/1073191113475808
65. Pincus AL, Ansell EB, Pimentel CA, Cain NM, Wright AGC, Levy KN.
Initial construction and validation of the pathological narcissism inventory. Psychol
Assess. (2009) 21:365–79. doi: 10.1037/a0016530
66. Schmitt DP, Realo A, Voracek M, Allik J. Why can’t a man be more like a
woman? Sex differences in big five personality traits across 55 cultures. J Pers Soc
Psychol. (2008) 94:168–82. doi: 10.1037/0022-3514.94.1.168
67. Zimmermann J, Müller S, Bach B, Hutsebaut J, Hummelen B, Fischer F. A
common metric for self-reported severity of personality disorder. Psychopathology.
(2020) 53:168–78. doi: 10.1159/000507377
68. Skodol AE, Gunderson JG, McGlashan TH, Dyck IR, Stout RL, Bender DS,
et al. Functional impairment in patients with schizotypal, borderline, avoidant,
or obsessive-compulsive personality disorder. Am J Psychiatry. (2002) 159:276–83.
doi: 10.1176/appi.ajp.159.2.276
69. Bach B, Simonsen S. How does level of personality functioning inform
clinical management and treatment? Implications for ICD-11 classification of
personality disorder severity. Curr Opin Psychiatry. (2021) 34:54–63. doi: 10.1097/
YCO.0000000000000658
70. Sleep CE, Hyatt CS, Lamkin J, Maples-Keller JL, Miller JD. Examining the
relations among the DSM-5 alternative model of personality, the five-factor model,
and externalizing and internalizing behavior. Personal Disord. (2018) 9:379–84.
doi: 10.1037/per0000240
71. Few LR, Miller JD, Rothbaum AO, Meller S, Maples J, Terry DP, et al.
Examination of the section III DSM-5 diagnostic system for personality disorders
in an outpatient clinical sample. J Abnorm Psychol. (2013) 122:1057–69. doi: 10.
1037/a0034878
72. Clarkin JF, Caligor E, Sowislo JF. An object relations model perspective on
the alternative model for personality disorders (DSM-5). Psychopathology. (2020)
53:141–8. doi: 10.1159/000508353
73. Leeman RF, Potenza MN. Similarities and differences between pathological
gambling and substance use disorders: a focus on impulsivity and compulsivity.
Psychopharmacology (Berl). (2012) 219:469–90. doi: 10.1007/s00213-011-2550- 7
74. Sedgwick P. Questionnaire surveys. BMJ. (2011) 343:d4449. doi: 10.1136/bmj.
d4449
75. Clarkin, J, Caligor E, Stern B, Kernberg O. The Structured Interview of
Personality Organization-Revised (STIPO-R). New York, NY: Personality Disorders
Institute, Weill Cornell Medical College (2016).
Frontiers in Psychiatry 13 frontiersin.org