Journal of Personality Disorders, 34, Special Issue, 104–121, 2020

© 2020 The Guilford Press

CALIGOR AND STERN
NPD AND OBJECT RELATIONS THEORY

DIAGNOSIS, CLASSIFICATION, AND

ASSESSMENT OF NARCISSISTIC PERSONALITY
DISORDER WITHIN THE FRAMEWORK OF
OBJECT RELATIONS THEORY
Eve Caligor, MD, and Barry L. Stern, PhD

Narcissistic personality disorder (NPD) remains a controversial diagnosis,

with lack of consensus on essential features of the disorder and its bound-
aries. Within the framework of object relations theory (ORT), core orga-
nizing, structural features define NPD and provide a coherent conceptual
framework for understanding clinical features of the disorder. In the ORT
model, both grandiose and vulnerable presentations of NPD are character-
ized by a specific form of self-pathology, reflecting the impact of a gran-
diose self-structure in the setting of borderline personality organization.
The grandiose self-structure provides some stability of self-functioning but
does not confer the self-regulatory capacities provided by normal identity
formation and is reliant on maintaining a sense of the self as exceptional.
We compare the ORT model of NPD to diagnostic criteria in the Alterna-
tive Model for Personality Disorders (AMPD) of the DSM-5, highlighting
significant correspondence between the two models as well as conceptual
differences.

Keywords: narcissistic personality disorder, pathological narcissism,

object relations theory, alternative model for personality disorders,
grandiose self-structure

The question of how best to define narcissistic personality disorder (NPD)—

both its core, essential features and its boundaries—remains an area of con-
troversy among both clinicians and personality disorder researchers. The
highly variable presentation of NPD, which includes both grandiose and vul-
nerable subtypes, a spectrum of severity ranging from moderate to extreme,
and significant intra-individual variability with regard to level of function-
ing (Cain, Pincus, & Ansell, 2008; Pincus & Lukowitsky, 2010; Russ et al.,
2008), has led to significant confusion with regard to core clinical features
of the disorder (Caligor, Levy, & Yeomans, 2015). Lack of conceptual and
diagnostic clarity, in turn, confounds clinical assessment and has compli-

From Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York
(E. G.); and Department of Medical Psychology in Psychiatry, Columbia University College of Physicians
and Surgeons, New York (B. L. S.).
Address correspondence to Dr. Eve Caligor, 122 E. 42nd St., Suite 3200, New York, NY 10168. E-mail:
ec8@cumc.columbia.edu

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 NPD AND OBJECT RELATIONS THEORY 105

cated treatment development. We present here a framework for conceptual-

izing, diagnosing, and assessing NPD based in contemporary object relations
­theory (ORT). We compare the ORT approach to the diagnosis with crite-
ria for NPD introduced in the Alternative Model for Personality Disorders
(AMPD) of the Diagnostic and Statistical Manual of Mental Disorders, fifth
edition (DSM-5; American Psychiatric Association [APA], 2013), highlight-
ing both significant functional and descriptive correspondence between the
two models, as well as fundamental conceptual differences. Within the model
of ORT, core organizing, structural features define NPD and provide a coher-
ent conceptual framework for understanding clinical features of the disorder,
tying together the highly variable presentations of NPD.

DIAGNOSTIC CHALLENGES AND EMERGING MODELS

The DSM-5 Section II (APA, 2013) approach to diagnostic classification of

NPD has focused on counting pathological traits and symptoms in order to
make a categorical diagnosis of personality disorder. This approach describes
a rather narrow and homogeneous group of individuals, characterized by a
pervasive pattern of grandiosity (in fantasy or behavior), need for admira-
tion, entitlement, and lack of empathy. However, while these criteria capture
important aspects of narcissistic pathology, it is generally agreed that this
approach fails to cover the broad range of patients receiving the diagnosis
(Ronningstam, 2009; Westen & Arkowitz-Westen, 1998), and also fails to
address impairments in self-regulation and affect regulation that can charac-
terize NPD (Cain et al., 2008; Pincus, Cain, & Wright, 2014; Ronningstam,
2009), including vulnerable self-esteem, feelings of inferiority, emptiness,
boredom, affective reactivity, emotional distress, and rage.
The Alternative Model for Personality Disorders (AMPD) introduced
in Section III of DSM-5 moves away from singular attention to pathologi-
cal traits and symptoms to focus as well on pathology of self and interper-
sonal functioning as core aspects of personality disorder, while emphasizing
the dimension of severity. The AMPD model for diagnosis of a personality
disorder requires both impairments in personality functioning (Criterion A)
and elevation of pathological traits (Criterion B). Criterion A is defined in
terms of impairments in self (identity and self-direction) and interpersonal
(intimacy and empathy) functioning of at least moderate severity. Severity
of impairment is rated from 0 to 4, ranging from little or no impairment
through extreme impairment, using the Level of Personality Functioning
Scale (LPFS), which provides prototypes for each level of severity. Criterion
B includes 25 pathological personality trait facets, organized in relation to
five higher-­order domains: Negative Affectivity, Detachment, Antagonism,
Disinhibition, and Psychoticism.
Within the framework of the AMPD, NPD is diagnosed on the basis of
specific pathology of self and interpersonal functioning coupled with patho-
logical traits of grandiosity and attention seeking. The AMPD criteria for
NPD are provided in Table 1. The AMPD criterion set for NPD covers a
broader range of clinical presentations than is covered in Section II, and is

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 106 CALIGOR AND STERN

TABLE 1. Criteria for Narcissistic Personality Disorder in the DSM-5 Alternative Model
of Personality Disorders
CRITERION A. Moderate or greater impairment in personality functioning, manifested by
characteristic difficulties in two or more of the following areas:
1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal
inflated or deflated, or vacillating between extremes; emotion regulation mirrors fluctuations in self-esteem
2. Self-direction: Goal setting based on gaining approval from others; personal standards unreasonably high in order
to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations
3. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to
reactions of others, but only if perceived as relevant to self; over- or under-estimate of own effect on others
4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little
genuine interest in others’ experiences and predominance of a need for personal gain
CRITERION B. Both of the following pathological personality traits:
1. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either covert or overt; self-centeredness; firmly
holding to the belief that one is better than others; condescension towards others
2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of oth-
ers; admiration seeking
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (Copyright
2013). American Psychiatric Association.

more inclusive of vulnerable as well as grandiose presentations of the disor-

der (Pincus, Dowgillo, & Greenberg, 2016). Specifically, criterion A for NPD
specifies that self-appraisal may be “inflated, deflated or vacillating between
extremes” and that “emotion regulation mirrors fluctuations in self-esteem.”
Negative affectivity (e.g., elevated depressivity, anxiousness, emotional labil-
ity) can be further included under trait specifiers, as can withdrawal and an-
hedonia (both under the higher-order domain of Detachment), often central
features of vulnerable presentations of NPD.
In shifting from a purely criterion-based framework to a hybrid system
combining impairments in self and interpersonal functioning with maladap-
tive traits, the DSM-5 AMPD aligned itself quite closely with the clinically
and theoretically based perspective on personality functioning and pathol-
ogy developed within the framework of object relations theory (Kernberg &
Caligor, 2005). When it comes to the diagnosis of NPD, the two models cor-
respond quite closely, from both a descriptive perspective (emphasis on gran-
diosity and need for admiration) and a functional perspective (characteristic
self-states and characteristic ways of relating to others). Key differences be-
tween the two models are more conceptual than operational and reflect the
traditions within which each model is embedded. Whereas the AMPD is em-
pirically based and a-theoretical, the ORT model benefits from an organizing
theory based in a psychodynamic model of psychological functioning.
ORT provides an integrated theory-based model of: (1) normal person-
ality functioning, (2) general features of personality dysfunction seen in per-
sonality disorders as a group, and (3) the specific dysfunction that character-
izes NPD. Because the ORT and AMPD models identify essentially the same
group of patients for the NPD diagnosis, the ORT model can be seen to pro-
vide a conceptual framework for the AMPD diagnosis and can help clinicians
understand how the various clinical features and diagnostic criteria of the
disorder relate to one another, as well as the relationship between grandiose
and vulnerable presentations of NPD. The model also provides a conceptual-

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 NPD AND OBJECT RELATIONS THEORY 107

ization of the relationship between pathological narcissistic traits and NPD

proper. The ORT model has led to the development of a theoretically based,
empirically validated model of diagnostic assessment (Stern et al., 2010) that
emphasizes severity of impairment in personality functioning.

CLINICAL FEATURES OF NPD

The ORT model of NPD emphasizes the following as essential clinical fea-
tures of NPD1 (1) a poorly integrated sense of self that leaves the individual
dependent upon sustaining a view of him- or herself as exceptional in order
to maintain the integrity of self-experience, self-regulatory processes, and af-
fective stability; (2) relationships with others that are transactional, lacking
in empathy, and of interest largely to the extent that they function to support
self-definition or self-regulation, enhance self-esteem, or promote personal
advancement; (3) childlike value systems (e.g., those focusing on wealth,
beauty, power, or fame) with variable pathology of moral functioning; (4)
a tendency to deny aspects of reality that challenge the individual’s sense of
specialness; and (5) subjective states characterized by feelings of emptiness2
(Kernberg, 2012). Some individuals with this constellation have a predomi-
nantly grandiose and arrogant presentation; others present as vulnerable,
shame-ridden, and depleted; still others fluctuate between grandiose and vul-
nerable presentations and self-states. Some are relatively high-functioning
individuals (who may appear “normal” on initial view); others present with
global and severe dysfunction. Regardless of presentation, all share common
structural features; it is at the level of structural organization of personal-
ity functioning that the relationships among clinical features can be seen to
emerge, and that core features of the disorder, underlying variability of clini-
cal presentation of NPD, can best be understood.

STRUCTURAL CLASSIFICATION OF PERSONALITY PATHOLOGY

AND LEVEL OF PERSONALITY ORGANIZATION

Identity is the cornerstone of the object relations theory-based model of per-

sonality disorders. Normal identity formation, or consolidated identity, is
associated with a sense of self and of significant others that is coherent and
continuous across time, characterized by specificity and depth as well as mul-
tifaceted, integrating both positive and negative qualities and associated with
affective experience that is integrated, well modulated, and well regulated.
Normal identity formation is associated with the capacity to pursue and in-
vest in long-term goals. The capacity for empathy also rests on the experience
of an integrated view of the self in relation to the other. In contrast, pathol-

1. We use the term NPD in this article to refer to the diagnosis as defined within the ORT and AMP mod-
els, covering both grandiose and vulnerable presentations.
2. Items 1 and 2, above, correspond closely with Criterion A in the AMPD and will lead to identification
of the same group of individuals. Items 3, 4, and 5, included in Kernberg’s description identify additional
clinical features considered central to NPD within the framework of ORT. In the AMPD, these features
can be included as specifiers.

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 108 CALIGOR AND STERN

TABLE 2. Classification of Personality Organization Within the Framework of ORT

Level of Personality Organization
(→ increasing severity)
Normal PO Neurotic PO High-Level BPO Mid-level BPO Low-Level BPO
No pathology Sub-syndromal Mild PD Severe PD Most severe PD
(LPFS 0) (LPFS 1) (LPFS 2) (LPFS 3) (LPFS 4)
Identity Formation Normal Normal Mild identity Identity pathology Identity pathology
pathology
Object Relations Deep Deep; may be Some dependent Need fulfillment, Callous disregard
conflicts relations may be exploitative of others; ruth-
less exploitation,
sadism
Defenses Mature High-level High-level and Splitting-based Splitting-based
(repression-based splitting-based
and mature)
Moral Functioning Present Present Variable; may be Significant pathol- Extreme pathology;
generally adequate ogy of variable antisocial behavior
or mildly impaired degree or absence of moral
values
Aggression Modulated Modulated Mild pathology; Aggression toward Extreme aggression
variable self/others towards self/others
Reality Testing Stable Stable Some vulnerability Vulnerable Vulnerable
Note. Severity increases left to right. Comparable Level of Personality Functioning Scale (LPFS) ratings are in parenthe-
ses beneath each level of organization. ORT: object relations theory; PO: personality organization; BPO: borderline
level of borderline level of personality organization.

ogy of identity formation is associated with views of self and others that are
superficial, distorted, discontinuous, and polarized—divided between experi-
ences that are wholly desirable and those that are wholly undesirable. Affects
are poorly integrated and poorly modulated. Failure of identity consolida-
tion is associated with difficulty identifying and sustaining longer-term goals
and impaired capacity for empathy (Kernberg & Caligor, 2005).
Within the framework of ORT, classification of personality pathology
focuses on core domains of functioning central to healthy personality func-
tioning and disrupted in personality disorders, specifically: (1) identity, (2)
object relations, (3) defensive operations, (4) quality and management of ag-
gression, (5) moral functioning, and (6) reality testing (Kernberg & Caligor,
2005). Assessment of the nature and level of organization of functioning in
these domains provides both a dimensional profile of personality function-
ing and a determination of the individual’s personality organization. Deter-
mination of personality organization, or level of personality organization,
leads to classification of personality disorders across a continuous spectrum
of pathology, ranging from healthy personality functioning through severe
pathology, and linking diagnostic classification to prognosis and treatment
planning (Caligor, Kernberg, Clarkin, & Yeomans, 2018). Table 2 outlines
classification of personality pathology by level of personality organization.
These five levels of personality organization serve as prototypes for clinicians
evaluating patients with personality pathology, focusing on the dimension of
severity.

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 NPD AND OBJECT RELATIONS THEORY 109

STRUCTURAL CLASSIFICATION OF
NARCISSISTIC PERSONALITY DISORDER

Within an ORT frame of reference, NPD falls in the borderline level of per-
sonality organization (BPO). As indicated in Table 2, linking the NPD diag-
nosis to BPO implies the presence of identity pathology and the predomi-
nance of dissociative, or splitting-based, defenses, as well as pathology of
object relations, a central role for aggression in personality functioning, vari-
able moral functioning, and potentially vulnerable reality testing.3 However,
at the same time that NPD is associated with significant pathology of identity
formation, it is also distinguished from other personality disorders (PDs) at
the BPO level by the presence of greater stability in self-functioning. This
greater stability manifests in relative specificity and consistency of the sense
of self and in the relative ability to invest in and pursue long-term goals when
compared to other personality disorders of similar severity. The structural
features of NPD are outlined in Table 3.
The relative stability of self-functioning seen in NPD reflects the impact
of a specific structural constellation organized in relation to a rigidly idealized
view of the self, which Kernberg (1984) has referred to as the pathological
grandiose self. The grandiose self-structure provides a degree of stability and
specificity of self-functioning, a facsimile of identity integration, that enables
some with NPD to be goal-directed and to function relatively well, despite
an underlying borderline level of personality organization. However, in con-
trast to normal identity formation, which confers stability of self-functioning
that is also flexible and based on realistic self-appraisal, the grandiose self is
a defensive structure, both rigid and brittle, whose integrity is predicated on
consistently maintaining a view of the self as exceptional. It is the grandiose
self that defines NPD within the framework of ORT and that distinguishes
NPD from other PDs organized at a borderline level.

CLINICAL ILLUSTRATION OF THE STABILIZING IMPACT OF

THE GRANDIOSE SELF ON SELF-FUNCTIONING

To illustrate the potentially stabilizing role of the grandiose self in personal-

ity functioning, even in individuals with relatively severe personality pathol-
ogy, we introduce Ms. A, seen with her husband in consultation for couples
counseling. Ms. A carries the diagnosis of NPD organized at a mid–BPO
(see Table 2). Forty-five years old, Ms. A has successfully battled her way to
senior partnership in a male-dominated, top-tier law firm. She maintains a
stable sense of herself as an exceptional, highly effective individual capable
of working harder than others to attain her objectives, someone who has
triumphantly escaped her cultural and family origins steeped in repressive
attitudes toward women. She is highly goal-directed, setting high standards
3.When we speak of vulnerable reality testing in personality disorders, we refer not to psychosis but rather
to a blurring of the distinction between internal, subjective experience and external reality. In NPD the in-
ternally driven need to support grandiosity may lead to gross distortion of external reality; the individual
experiences his wished-for self (internal reality) as if it were his actual self (external reality), for example
maintaining a conviction of being “an expert” while grossly lacking relevant knowledge and experience.

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 110 CALIGOR AND STERN

TABLE 3. Core Structural Features of Narcissistic Personality Disorder

Within the Framework of Object Relations Theory
Identity
Object relations
Defensive operations
Aggression
Moral functioning
Reality testing
Failure of normal identity consolidation; presence of compensatory grandiose self-
structure, which may provide sense of self that has some stability and specificity; in
contrast, sense of others is vague, superficial; variable capacity to invest in long-term
goals; affect regulation tied to self-valuation
Limited sense of the needs of the other, independent of the needs of the self; superfi-
cial, transactional relationships may be overtly exploitative; problems with intimacy;
boredom
Predominantly splitting-based/dissociative defenses—in particular, idealization and
devalution, dissociation, projection, denial
Variable depending on severity, but prominent in psychological functioning
Pathology of value sytems and moral functioning reflected in childlike values (fame,
glamour, wealth), shame over guilt, often with moral “lacunae,” possibly with frank
antisocial features
Denial of realities that challenge grandiosity, potentially resulting in gross distortion of
reality

for herself and successfully meeting them. When asked to describe herself,
Ms. A. provided a specific, detailed description consistent with the experi-
ence of the interviewer.
In contrast with her stable and well-defined sense of self and her high
level of vocational functioning, Ms. A’s sense of others and her interperson-
al functioning demonstrate severe impairment. When asked to describe her
husband, Ms. A was able to provide only a highly superficial caricature-like
description, lacking detail and consistently devaluing: “He’s soft, passive,
getting fat.” When asked if she could identify any positive features in her
husband, Ms. A responded: “Not much there....I guess he takes care of the
household, manages the nanny.”
Ms. A has no significant friendships and no relationship with her family
of origin. She believes that it is her husband’s role in the marriage to accom-
modate her needs. She habitually flies into an entitled rage when he fails to
do so, on occasion physically assaulting him. Mr. A describes being fearful of
leaving Ms. A alone with their 6-year-old daughter; when the daughter fails
to follow her instructions, Ms. A will bully her until she bends to Ms. A’s
will. Ms. A experiences no remorse in relation to her outbursts, externalizing
blame onto others.
We can draw a comparison between Ms. A’s self-functioning and that of
Ms. B, also organized at a mid–BPO but without the stabilizing impact of
the grandiose self, carrying the diagnosis of borderline personality disorder.
Forty years old and married, Ms. B has been unemployed since graduating
from college, supported initially by her parents and currently by her hus-
band. When alone, she becomes anxious and relies on superficial cutting to
soothe herself. She describes herself as aimless and directionless, with no
personal or professional goals and no idea of who she is, what she wants,
or where she is going. She responded with confusion to the request that
she provide a self-description—“How can I describe myself when I have
no idea who I am?” Her description of her husband was internally con-
tradictory, self-­referential, and superficial: “He’s okay . . . takes good care of
me. . . . He’s boring, does not make enough money.” Ms. B’s relationships

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 NPD AND OBJECT RELATIONS THEORY 111

are stormy, affectively charged, and unstable; she routinely throws tantrums
when frustrated or disappointed. Like Ms. A, Ms. B is often rageful toward
her daughter, though she also demonstrates moments of tenderness with her
child, as well as remorse in relation to her outbursts.

Comments. Ms. A demonstrates a stable and specific, albeit somewhat su-

perficial and grandiose sense of self, and a capacity for goal-directed be-
havior. This level of relative stability, incongruent with the severity of her
personality pathology, reflects the impact of the grandiose self on personality
functioning. At the same time, Ms. A’s rage when confronted with the opin-
ions or needs of others illustrates the extreme rigidity and self-regulatory
failures also associated with the grandiose self. In contrast to the relatively
stable self-functioning that characterizes Ms. A’s presentation, Ms. B has an
evident identity disturbance marked by a chaotic, contradictory, and inter-
nally confusing self-experience and corresponding experiences of others. In
the absence of an organized sense of self, she is unable to pursue short- or
longer-term goals, and her subjective experience is one of aimlessness and
meaninglessness.
In sum, within the framework of ORT, NPD is a specific personality
disorder defined by the presence of a grandiose self-structure in the setting
of BPO. Many different forms of personality pathology may present with
features of pathological narcissism (inflated self-image, entitled expectations,
exploitative self-enhancement, self-serving beliefs) of variable degree—or for
that matter, with narcissistic vulnerability (self and affective dysregulation in
response to disappointed expectations and self-enhancement failures, feel-
ings of envy, resentment, retreat to fantasy, withdrawal). But only when nar-
cissistic grandiosity and vulnerability are organized in relation to a grandiose
self-structure will the diagnosis of NPD be made. This, in essence, defines the
conceptual boundary of the disorder, applying across grandiose and vulner-
able presentations, as well as across the entire range of severity within the
BPO spectrum.

INTERNAL OBJECT RELATIONS, IDENTITY FORMATION,

AND SELF-STATES IN NPD

In order to more fully understand the grandiose self and the structural fea-
tures of NPD, it is helpful to have a basic understanding of internal object re-
lations (IORs) and their relationship to personality organization. Within the
framework of ORT, IORs are internalized relationship patterns that organize
subjective experience and interpersonal behavior. An IOR is composed of a
representation of the self-linked to a representation of another person and
associated with a particular affect state. In the ORT model, IORs function as
the building blocks of higher-order structures—in particular, identity. In nor-
mal identity formation, different IORs organizing the experience of self and
other have coalesced to form a flexibly integrated, multifaceted, and stable
self-structure that interacts with others who are also experienced as complex
and multifaceted.

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 112 CALIGOR AND STERN

In contrast, in the setting of borderline personality organization (BPO),

individual object relations are not organized to form an integrated central
sense of self or of others; rather, internal object relations organizing the ex-
perience of self and other are split—polarized so that they are extreme, be-
ing either “all good” or “all bad,” with object relations of opposite valence
mutually dissociated from one another. This level of psychological organiza-
tion is seen to reflect the impact of splitting-based defenses in the setting of
an excess of aggression. The outcome is a psychological situation in which
dissociated, contrasting idealized (all good) and paranoid or devalued (all
bad) dyads organize the experience of self and other moment to moment,
while the predominance of aggression leads to an overall paranoid orienta-
tion. This organization accounts for the extreme and distorted, unstable, and
largely paranoid experience of self in relation to other that is the hallmark
of the BPO in general and of borderline personality disorder in particular
(Kernberg & Caligor, 2005).
In NPD, superimposed on this underlying organization—and protect-
ing against anxieties associated with the paranoid orientation and the ex-
treme and unstable quality of internal experience characteristic of BPO—is
the grandiose self-structure. In contrast to the idealized and paranoid dyads
of self in relation to other that are the building blocks of identity in BPO,
the grandiose self-structure is comprised solely of ideal representations, all
attributed to the self; in the grandiose self-structure, idealized self-represen-
tations and idealized representations of others are condensed and substitute
for an authentic sense of self (Kernberg, 1984). In essence, the grandiose self
is a defensive structure that both establishes and reassures: “I am all that is
desirable; there is nothing of value that I lack; everything outside of me is
inferior.” The need for others is denied, as is the central role played by in-
ternal representations of dyadic relationships in organizing identity and the
internal world.
Grandiose states in NPD reflect a conscious identification on the part
of the individual with the grandiose self, while corresponding, condensed
devalued self and other representations are dissociated and projected out-
ward. The subjective outcome is a more or less stable sense of a superior self
in a world of devalued others, inferior and contemptible, who are needed to
maintain the grandiose self but otherwise of little interest. To the extent that
this constellation is stably sustained, individuals with NPD may be largely
asymptomatic (see Mr. H, below). In contrast, in vulnerable states the indi-
vidual with NPD is consciously identified with condensed, devalued repre-
sentations of self and other, while projecting corresponding idealized repre-
sentations onto the people in his or her world. The subjective outcome is an
inferior, humiliated, contemptible, and persecuted self in a world of superior,
contemptuous others.
Individuals corresponding to the so-called “vulnerable subtype” of NPD
(Wink, 1991) are consistently, stably, and consciously identified with deval-
ued representations, living in a constant state of self-devaluation (see Mr. V,
below). However, despite their manifest self-deprecation, these individuals
nevertheless retain a psychological connection to the grandiose self, albeit
one that is superficially hidden by self-devaluation and misery and is dissoci-

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 NPD AND OBJECT RELATIONS THEORY 113

ated from dominant self-experience.4 This connection is responsible for co-

vert grandiosity, dissociated from dominant self-experience, and is expressed
as grandiose fantasy, intense feelings of resentment, envy, and injustice at not
being recognized, all central to the experience of individuals with vulner-
able presentations of NPD. These attitudes, discordant with the individual’s
manifest self-devaluation, and expressions of the grandiose self, can help to
distinguish vulnerable presentations of NPD from narcissistic vulnerability
in other forms of personality pathology. In the same way that manifestly
vulnerable narcissists retain a connection to their grandiosity, manifestly
grandiose narcissists, even the most stably grandiose, are not fully protected
from the experience of the devalued self, which threatens to emerge into con-
sciousness in the setting of disappointments or failure. Thus, even the most
grandiose narcissist may have internal feelings of inadequacy or fraudulence,
as well as the potential of flipping into a vulnerable state, and by definition
there is a grandiose self hidden behind the manifest self-devaluation of those
in vulnerable states.

IMPACT OF THE GRANDIOSE SELF-STRUCTURE

ON PERSONALITY FUNCTIONING

The model of the grandiose self-structure co-occurring within a BPO provides

an integrated framework for elaborating and understanding the characteristic
clinical features of NPD introduced above and mirrored in the AMPD criteria.
While providing some stability of self-functioning that may support adapta-
tion, the sense of self `associated with the grandiose self-structure is not mere-
ly grandiose but also superficial, rigid, more or less unstable, and to a greater
or lesser degree distorted, based on splitting-based defenses—­idealization,
dissociation, and projection, supported by denial—in the setting of poorly
integrated aggression. Self-valuation and self-definition are condensed and
conflated such that not only self-esteem but the entire sense of self, along with
affective stability and self-regulation, is reliant on maintaining a view of the
self as exceptional. Instead of integrated and internalized value systems, what-
ever enhances and supports grandiosity in the moment is valued.
To the extent that the grandiose self-structure can provide some degree of
stability to personality functioning, that stability is reliant on ongoing support
from the environment. When narcissistic supplies are not available and self-
enhancing strategies fail to reestablish equilibrium—for example, when the in-
dividual meets with disappointments, frustrations, or setbacks that cannot be
denied—the superficial stability provided by the grandiose self breaks down.
For predominantly grandiose narcissists who may function adequately while
grandiosity is supported, destabilization of the grandiose self corresponds to a
loss of the self-definition and goal directedness typically provided by the gran-
diose self as identifications with devalued representations come to organize

4. The hidden connection with the grandiose self in those presenting with the vulnerable subtype of NPD
reflects the impact of projective identification. The individual projects the grandiose self onto others while
maintaining a dissociated connection to what is projected.

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 114 CALIGOR AND STERN

subjective experience. This process is experienced as an abrupt shift from pre-

dominantly positive or neutral affect states to an experience of being flooded
by painful negative affects linked to self-depreciation and feelings of meaning-
lessness and futility. For those with predominantly vulnerable presentations,
disappointments and setbacks that challenge covert grandiosity typically lead
to enhanced feelings of resentment and envy, increased symptoms of depres-
sion and anxiety, social withdrawal, and an increase in what is often chronic
suicidal ideation, with risk of suicide (Pincus et al., 2009).
The distinctive quality of interpersonal functioning associated with NPD
reflects denial of the dyadic nature of both internal experience and interper-
sonal reality intrinsic to the grandiose self-structure. In essence, within the
psychological universe of the grandiose self-structure, there are no internal
object relations (IORs) but only an ideal self, composed of a condensation of
idealized self and other representations, in relation to a devalued self com-
posed of devalued self and other representations. Others are not experienced
as individuals but as extensions of the self that function to support self-­
regulation by reinforcing grandiosity or containing projected, devalued as-
pects of the self; exchanges between people become functional transactions
with the single, specific aim of supporting the grandiose self, being otherwise
of little genuine interest or value. Simultaneous denial of IORs and devalua-
tion of others in the external world are seen to account for the profound feel-
ings of emptiness often associated with NPD, while the nonspecific quality of
the experience of others so characteristic of NPD enables the individual with
NPD to deny awareness that others have specific attributes and capacities
that the individual may lack, an awareness that would directly challenge the
requisite sense of global superiority required to maintain the grandiose self.
The need to avoid contact with realities that might challenge grandiosity not
only colors the individual’s experience of others in NPD, but also extends to
the individual’s total relationship to external reality and can subtly impact
reality testing; aspects of reality that threaten grandiosity are consistently
distorted, denied, or withdrawn from.

LEVELS OF PERSONALITY ORGANIZATION AND NPD

Among the different personality disorder types, NPD presents across the
widest range of severity of pathology (Kernberg, 2012). The NPD diagno-
sis can be seen to range from high-level BPO through low-level BPO, with
deteriorating quality of object relations, decreasing moral functioning, and
increasing antisocial features, as well as increasing infiltration of personality
functioning with poorly integrated aggression (which may be self-directed
as well as directed toward others) as pathology becomes more severe. With
increasing severity, we also see changes in the nature of identity formation.
Specifically, with increasing severity, the idealized representations organizing
the grandiose self-structure and associated grandiose states become increas-
ingly affectively charged, infused with aggression, and extreme in their gran-
diosity, as well as increasingly out of touch with reality.5 At the same time,

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 NPD AND OBJECT RELATIONS THEORY 115

with increasing severity the organizing functions of the grandiose self break
down, revealing underlying identity pathology and the dysregulation char-
acteristic of BPO. Both grandiose and vulnerable presentations can be found
at any level of personality organization, although the most high-functioning
individuals tend to be stably grandiose, and those constantly in depreciated,
vulnerable states tend to be poorly functioning.
To illustrate the variable presentation and range of severity that char-
acterize the NPD diagnosis, we will present three clinical vignettes. All
three patients meet both ORT criteria (see Table 3) and AMPD criteria (see
Table 1) for NPD, and all three individuals present with a borderline level
of personality organization in conjunction with a grandiose self-structure.
The vignettes illustrate both the grandiosity and the potential stabilization
of self-functioning conferred by the grandiose self-structure. This is most
evident in the case of Mr. H, who has consistently invested in his profession
and who demonstrated a specific and stable, though somewhat grandiose
sense of himself. Another patient, Mr. G, has also been able to commit to
a profession and to maintain a history of consistent work performance as
long as things go relatively well for him; his sense of self is also relatively
specific and well developed, though more overtly distorted by grandiosity
than that of Mr. H. Mr. V, in contrast, demonstrates covert gradiosity along
with the more overt pathology of self-functioning typically seen in BPO,
presenting with a lack of goal directedness and a vague and superficial
sense of himself, consistent with his diagnosis of co-occurring borderline
personality disorder.

MR. G

Mr. G is 34 years old and single, with a history of cocaine and alcohol mis-
use, currently unemployed. He presented to the ER following a dental proce-
dure, complaining of pain and requesting Percocet. Though initially charm-
ing and ingratiating with the female attending physician, when she explained
that she would have to speak with his oral surgeon before writing a pre-
scription for narcotics, he began to insult and bully her. When the ­attending
physician spoke with Mr. G’s girlfriend, who had accompanied him to the
ER, she expressed her frustration with Mr. G; since being fired from a high-
paying financial job one year prior, he had been unable to find employment
that met his lofty expectations for himself. He preferred to isolate himself
while living off money from his father and girlfriend. His girlfriend explained
that ­before losing his job, Mr. G had been “a completely different guy”—­
outgoing, ­expansive, generous to a fault, and always picking up the tab in
social situations.

5. At the most severe end of the NPD spectrum is the syndrome of malignant narcissism (Kernberg, 1984,
2012), in which poorly integrated, extreme aggression entirely dominates personality functioning and
is associated with severe paranoia and vulnerable reality testing. Object relations are characterized by
coldhearted, sadistic cruelty, and moral functioning is marked by antisocial behavior and psychopathic
features.

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 116 CALIGOR AND STERN

Comment. We identify Mr. G’s personality organization at a mid-level BPO

on the basis of: (1) object relations founded on need fulfillment and some
degree of exploitation, but free of significant sadism and with some capacity
for sustained relationships; (2) pathology of moral functioning marked by
lying and the possibility of antisocial behavior in the service of procuring
narcotics; (3) moderate aggression with bullying but no history of physical
violence; and (4) vulnerable reality testing evidenced in his absolute con-
viction that accepting a job less prestigious than his previous employment
would mark him for life as “damaged goods.” Mr. G is an example of the
grandiose subtype of NPD emphasized in DSM-5’s Section II, and he also
meets criteria for NPD within the diagnostic framework of the AMPD, with
severe (LPFS 3) impairment in self-direction, identity, empathy, and intimacy.
Trait elevations include antagonism and disinhibition. Facet-level elevations
include grandiosity, attention seeking, hostility, manipulativeness, callous-
ness, deceitfulness, and irresponsibility.

MR. V

Mr. V, a single 29-year-old man, has a history of insulin-dependent diabetes

mellitus. He presented to an outpatient clinic for treatment of “dysthymia
and social phobia.” Having held a series of low-level jobs that “have not
worked out,” he currently works part-time from home doing data entry. On
further inquiry, it emerged that he had been fired from his last job after
stealing office supplies and using company credit cards to make personal
purchases; he explained that he had felt entitled to do so given his low-level
hourly pay.
Mr. V describes his mood as chronically “miserable.” Socially isolated
and easily slighted, he has no interests, takes pleasure in nothing, and rou-
tinely wonders “whether life is worth living.” When feeling down, he often
“forgets” to self-administer his insulin and then lies about this to his long-
time physician, resulting in multiple hospitalizations for dangerously high
blood sugar and multiple medical complications from his diabetes. He ap-
pears not at all concerned but instead is triumphant as he describes these
episodes. He constantly compares himself to others, feeling envious and
resentful. He describes himself as deficient and defective, but at the same
time actively resents the failure of others to recognize all he has to offer. He
fantasizes about his employer publicly acknowledging his special talents and
promoting him; at other times, he has fantasies of humiliating his boss with
a display of superior knowledge.

Comment. We locate Mr. V’s personality organization at a low level BPO on

the basis of: (1) object relations marked by the absence of any relationships
beyond that with his regular physician, which is characterized by chronic
deception and perversion of a normal caregiving relationship; (2) severe pa-
thology of moral functioning characterized by a history of frank antisocial
behavior in the workplace, as well as chronic lying and deception; and (3)
recurrent ego-syntonic, self-directed, and even life-threatening expression of

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 NPD AND OBJECT RELATIONS THEORY 117

aggression supported by extreme denial of the reality of its dangerousness.

Mr. V is an example of an individual presenting the profile of the vulner-
able subtype of NPD—in this case, co-occurring with borderline personality
disorder. He meets AMPD criteria for both NPD and BPD, with extreme im-
pairment in identity, goal directedness, intimacy, and empathy (LPFS 4). Trait
elevations include negative affectivity, detachment, antagonism, and disinhi-
bition. Facet-level elevations include anxiousness, hostility, depressivity, re-
stricted affectivity, withdrawal, avoidance, anhedonia, grandiosity, attention
seeking, irresponsibility, and risk taking.

MR.H

Mr. H is a 52-year-old married man who presented to a psychotherapist in

private practice complaining of problems with his wife. A successful entre-
preneur and highly competitive, he describes enjoying social gatherings in
which he tends to be the center of attention, as well as challenges at work,
where he believes that he has superior ability to solve any problem. He has
a large social circle and is on the governing boards of several local charities.
Though charming, he demonstrates a dismissive attitude toward those he
feels have little to offer him. He endorses a single past episode of depression
while in college, in which he “fell into a hole” after failing a placement exam
for an engineering major.
Mr. H comes to treatment wondering whether to stay in his marriage but
otherwise denying all problems. He describes having lost all sexual interest
in his wife during their early years together. Throughout the marriage, he
has maintained a series of lovers whom he has housed, supported, and then
cut off and replaced. He feels that this arrangement has had no impact on
his relationship with his wife, but wonders if he would do better if he were
married to someone else. He has lied to his wife about his infidelities, free
of shame or conflict; otherwise, he denies antisocial features. He provides a
three-dimensional, lively self-description; in contrast, his description of his
wife is vague, superficial, and generic.

Comment. While presenting with a stable and specific sense of self, the pov-
erty of Mr. H’s experience of his wife and of significant others is an indica-
tion of the presence of clinically significant identity pathology, placing him
in the BPO range—along with Mr. G and Mr. V—despite his high level of
functioning. We would locate Mr. H at a high level BPO based on: (1) object
relations that are transactional in nature but free of exploitation, demon-
strating a capacity for sustained relationships with an incapacity for inti-
macy and impairment of empathy; (2) moral functioning marked by lying
to conceal his infidelity, but otherwise no evidence of moral pathology and
no antisocial behavior; (3) pathological expression of aggression limited to
devaluation of his wife and a dismissive attitude toward those he feels have
little to offer him; and (4) some distortion of reality embedded in his con-
cretely held assessment of his global superiority and capacity to “solve any
problem.” Mr. H illustrates the high-functioning subtype of NPD described

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 118 CALIGOR AND STERN

in the literature (Russ, Shedler, Bradley, & Westen, 2008). While he would
not be diagnosed with NPD by DSM-5 Section II criteria, he does meet
AMPD criteria for NPD, with mild–moderate impairment in identity, mild
impairment in self-direction, and moderate impairment in empathy and in-
timacy (LPFS 2). Trait elevation is for the most part limited to antagonism,
with facet elevations including grandiosity, attention seeking, deceitfulness,
callousness, and hostility.

ASSESSMENT

Diagnosis of NPD within the framework of object relations theory (ORT)

is organized in relation to the defining, structural features of the disorder,
focusing on identity, defenses, quality of object relations, moral function-
ing, aggression, and reality testing. Diagnostic evaluation can be performed
in the setting of a clinical interview or a semistructured interview process
(Hörz-Sagstetter et al., 2018). The Structured Interview of Personality Or-
ganization (STIPO-R) (Clarkin, Caligor, Stern, & Kernberg, 2016) is a sem-
istructured interview that evaluates personality organization and includes
a narcissism scale. Structural assessment provides a profile of personality
functioning, identifying degree of impairment of functioning in each of the
six domains. This profile can be used to make a diagnosis of overall level of
personality organization. Whether by semistructured or clinical interview,
diagnosis of NPD will emerge most clearly in the process of evaluation of
identity ­formation—in particular, self-esteem regulation and the sense of self
and sense of others­—­and object relations, the area of functioning in which
narcissistic pathology is often most evident.
Assessment of identity formation in relation to self-esteem regulation in
NPD focuses on the individual’s need for admiration in order to maintain
emotional stability. In Table 4, we present items adapted from the STIPO-R
to illustrate the assessment of self-esteem regulation as part of evaluation of
identity formation.
Exploration of self-regulation is complemented by the request for a self-
description and a description of a significant other. Individuals with NPD
have a characteristic pattern of response to this line of inquiry that directly
reflects the impact of the grandiose self on psychological experience, as out-
lined earlier. In the typical individual functioning at a BPO level, descriptions
of both self and other tend to be superficial, vague, polarized, and contra-
dictory, and the request for a self-description often presents an especially
confusing and challenging task. In contrast, in NPD, descriptions of the self
tend to be relatively specific and realistic (though typically inflated or unduly
deflated) and may not be strikingly different from those provided by indi-
viduals with normal identity consolidation. At the same time, descriptions
of significant others in NPD are marked by extreme poverty of content and
detail, being vague, superficial, almost blank, and accompanied by overall
idealized or devalued attributions. Even with prompting, descriptions remain
empty, seeming to reflect an inability to take in specific attributes of the other.

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 NPD AND OBJECT RELATIONS THEORY 119

TABLE 4. Assessing Self-Esteem Regulation: Sample Questions

• Although everyone appreciates being admired, would you say that other people’s approval, admiration, and posi-
tive attention are very important to you? Do you find yourself feeling empty or down when you are not receiving
attention or admiration?
• Would you say that there are significant swings or shifts in your sense of self-esteem, or that it is fairly stable?
• Would you say that your self-esteem alternates between your seeing yourself as special and wonderful at times, and
at other times as small and defective?
• Does your self-esteem depend a lot on how you are seen by others, or would you say that your self-esteem comes
from inside of you? Do you compare yourself to others a lot?

The diagnostic evaluation of identity in NPD is complemented by assess-

ment of object relations, focusing on the transactional, need-fulfilling, and
self-enhancing orientation to relationships that is so central to the disorder,
coupled with a tendency to shift between highly valued and highly devalued
experiences of relationships. We provide items adapted from the STIPO-R
to illustrate a tactful yet straightforward approach to this line of inquiry in
Table 5.
Once assessment points to the diagnosis of NPD, it becomes essential
to evaluate the severity of pathology, distinguishing among high-, mid-, and
low-level BPO presentations. Assessment will focus on differentiating be-
tween the transactional and need-fulfilling orientation toward relationships
seen even in healthier presentations of NPD (e.g., Mr. H, discussed earlier)
and more severe pathology of object relations marked by different degrees
of exploitation, parasitism, and various forms of bullying, intimidation, and
sadistic control of others (e.g., Mr. G) or complete withdrawal (e.g., Mr.
V). Next, moral functioning and antisocial features are specifically assessed:
Does the individual follow an internal code of moral behavior, or does s/he
feel above the rules or follow them only for fear of being caught? Does s/he
tend to tell lies, or is there a history of plagiarism, infidelity, frankly illegal ac-
tivities or run-ins with the law? Finally, assessment of the role of aggression
in the individual’s functioning is central to assessment and treatment plan-
ning, with specific inquiry into a history of self- or other-directed aggression,
including verbal threats and outbursts, physical intimidation, and violence.

CONCLUSION

In this article, we have introduced an approach to narcissistic pathology

based in ORT and emphasizing structural features of the disorder across
the dimension of severity, and we have addressed the significant overlap be-
tween the ORT approach to diagnosis and classification of NPD and the
approach introduced in the AMPD of the DSM-5. This overlap represents
the convergence of two models, one a-theoretical and empirically based, the
other embedded in psychodynamic theory and clinical observation, in de-
fining the central clinical features of NPD. The two models identify similar
pathology of self and interpersonal functioning as core to the disorder; both

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 120 CALIGOR AND STERN

TABLE 5. Assessing Quality of Object Relations: Sample Questions

• Do you tend to think about relationships in terms of what you can get out of them? Do you spend time thinking
about out who is getting more? Do you find yourself “keeping score”?
• In your mind, do you tend to divide people into groups—for example, one category of those who are excellent,
admirable, and enviable, and another of persons who are less desirable, either boring or not up to your level in
terms of looks, intelligence, wealth, or other qualities?
• Would you say that you seek out people in the admirable group with the thought that it will reflect well on you,
that it will improve your social standing?
• Do you tend to put people on a pedestal, to expect a lot of them? Does it follow that, after a while, you find
yourself very disappointed in them, feeling they have not lived up to what they had promised or to what you had
hoped?

view grandiosity as central to narcissistic pathology, and both emphasize the

dimension of severity as central to course and outcome. Though this has not
yet been empirically tested, the two models appear to identify the same group
of patients as meeting criteria for NPD. Finally, there are strong correlations
between LPFS ratings on the SCID-AMP and ratings of levels of personality
organization on the STIPO (Kampe et al., 2018).
There are also significant differences between the two models, largely
reflecting the different traditions within which they are embedded. The
AMPD is purely descriptive, while the ORT model also focuses on psy-
chological structures. Where the AMPD is a-theoretical (some might say
pan-theoretical), the ORT model is based in a fully elaborated psychody-
namic model of personality functioning and pathology. Perhaps the most
significant difference between the two models is that in the ORT model,
the nature of defensive functioning, moral functioning, reality testing, and
management of aggression are considered integral to the diagnosis, and
these features are seen to provide incremental validity over and above the
contributions from self and interpersonal functioning when it comes to de-
termining a clinically relevant assessment of severity of pathology (Caligor
et al., 2018; Kampe et al., 2018; Lenzenweger, Clarkin, Caligor, Cain, &
Kernberg, 2018). The LPFS, in contrast, takes a narrower view, seemingly
limiting the diagnosis of NPD and assessment of severity of personality pa-
thology to self and interpersonal functioning alone, while including moral
functioning, aggression, and reality testing as trait specifiers.
In sum, within the framework of ORT, the diagnosis of NPD is reserved
for a specific form of pathological narcissism defined neither on the basis
of presenting traits and symptoms nor on the basis of severity per se, but
rather on the basis of underlying structural features that organize personal-
ity functioning. It is the presence of a pathological, grandiose self-structure
in the setting of a borderline level of personality organization that defines
NPD and accounts for the clinical features of the disorder (Kernberg, 1984).
Within this framework, narcissistic traits are not viewed as isolated phenom-
ena, but rather are conceptualized within the larger context of personality
functioning, focusing on identity formation, quality of object relations, de-
fenses, moral functioning, aggression, and reality testing.

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 NPD AND OBJECT RELATIONS THEORY 121
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