760 vII. APPLICATIONS  AND  IMPLICATIONS
American concept. It was also initially slated 
for deletion in DSM-5 (Skodol, 2012) de -
spite the presence of a considerable amount 
of clinical interest (Pincus & Lukowitsky, 
2010; Ronningstam, 2011-a) and support -
ive empirical research (Miller, Widiger, & 
Campbell, 2010; Pincus & Lukowitsky, 
2010). In response to objections from col -
leagues within the personality disorder field, 
the DSM-5 Personality Disorders Work 
Group rescinded its proposal for its deletion 
(Skodol et al., 2013).
Narcissism is associated with a variety 
of self-  enhancement and self-  promotional 
strategies (Miller et al., 2010). Narcissistic 
persons tend to make a good first impres -
sion, but likability diminishes with increased 
familiarity. Over the course of time, narcis -
sism has a negative impact on relationships, 
as it is linked to manipulation and infidelity 
(Campbell & Miller, 2013). Narcissistic in -
dividuals’ inflated self-  esteem may also con -
tribute to an eventual career failure, as they 
lack an adequate appreciation of the limita -
tions of their proposals, abilities, and plans.
There has been some concern that the 
DSM-5 Section II criterion set for NPD may 
place too much emphasis on a grandiose 
narcissism, which can be associated with 
actual success in work and career, failing 
to adequately recognize a vulnerable nar -
cissism indicated by a need for admiration, 
self- devaluation, and hypersensitive feelings 
of vulnerability, humiliation, or rage in re -
sponse to criticism or rebuke (Miller et al., 
2010; Pincus & Lukowitsky, 2010). Persons 
with grandiose narcissistic traits at times ex -
perience episodes of self-doubt and vulner -
ability (Gore & Widiger, 2016). Conflicts 
and deficits with respect to self-  esteem are 
considered to be central to the pathology of 
the disorder (Ronninstam, 2005). Narcis -
sism involves a pathological regulation of 
pride and shame, which serves to protect 
and enhance the self (Tracy, Cheng, Mar -
tens, & Robins, 2011). Narcissistic persons 
must continually seek and obtain signs and 
symbols of recognition to compensate for 
conscious or perhaps even unconscious feel -
ings of inadequacy. Narcissism is not simply 
arrogant self-  confidence, as it is more highly 
correlated with an instability in self-  esteem 
than with a consistently high self-  confidence 
(Ronningstam, 2011b).Personality Disorders and  Personality
Although a considerable body of research 
supports the clinical importance of psycho -
pathic, schizotypal, borderline, dependent, 
and narcissistic personality traits, it is also 
evident that the DSM personality syndromes 
are not well understood as distinct diagnos -
tic categories. The many problems with DSM 
categorical classification have been well 
documented, including the heterogeneity in 
the traits among persons sharing the same 
diagnosis, the absence of a distinct bound -
ary with normal personality, and substan -
tial overlap and diagnostic co-  occurrence 
(Clark, 2007; Livesley, 2007; Skodol, 2012; 
Widiger & Trull, 2007). The DSM person -
ality disorders describe overlapping and 
complex syndromes, or constellations of 
maladaptive personality traits (Lynam & 
Widiger, 2001). As such, they lack specific 
etiologies, pathologies, and treatments.
There is also a substantial body of re -
search to support an understanding of the 
personality disorders as extreme and/or 
maladaptive variants of the traits included 
within the well-  validated dimensional five- 
factor model (FFM) of general personality 
structure (Widiger, Samuel, Mullins-  Sweat, 
Gore, & Crego, 2012), a hypothesis first 
proposed by Costa and McCrae (1990). The 
FFM, as traditionally conceptualized, com -
prises the five broad domains of neuroticism, 
extraversion (vs, introversion), openness (or 
unconventionality), agreeableness (vs. antag -
onism), and conscientiousness (vs. disinhibi -
tion) (Widiger, 2017). Collectively, the five 
domains, each of which includes an array of 
adaptive and maladaptive personality traits, 
readily incorporate the DSM-5 Section II 
personality disorder syndromes (Widiger & 
Trull, 2007; Widiger et al., 2012).
Table 36.1  provides a description of the 
antisocial, borderline, schizotypal, depen -
dent, and narcissistic personality disorders 
from the perspective of the FFM. The exten -
sive empirical support for these FFM con -
ceptualizations has been summarized for 
the antisocial (Derefinko & Lynam, 2013), 
borderline (Trull & Brown, 2013), schizo -
typal (Edmundson & Kwapil, 2013), depen -
dent (Gore & Pincus, 2013), and narcissis -
tic (Campbell & Miller, 2013) personality 
disorders. Self-  report inventories for the as -