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The views and opinions expressed in this report are those of the authors and should not be construed torepresent the views of sponsoring organizations, agencies, or the U.S. government. The National Epi-demiologic Survey on Alcohol and Related Conditions is funded by the National Institute on AlcoholAbuse and Alcoholism, with supplemental support from the National Institute on Drug Abuse. Thisresearch was supported in part by the Intramural Program of the National Institutes of Health, NationalInstitute on Alcohol Abuse and Alcoholism.

DOI: 10.1037/14041-011Understanding and Treating Pathological Narcissism,J. S. Ogrodniczuk (Editor)Copyright 2013 by the American Psychological Association. All rights reserved.

11SEX AND RACEETHNICDIFFERENCES IN PSYCHIATRICCOMORBIDITY OF NARCISSISTIC

PERSONALITY DISORDER

ATTILA J. PULAY AND BRIDGET F. GRANT

Narcissistic personality disorder (NPD) is characterized by a pervasivepattern of grandiosity, need for admiration, interpersonal exploitativeness,and lack of empathy, beginning in early adulthood and manifested in a vari-ety of contexts. Among the 10 personality disorders defined in the Diagnosticand Statistical Manual of Mental Disorders(4th ed.; DSMIV;American Psy-chiatric Association, 1994), NPD has received the least empirical attention(Cramer, Torgersen, & Kringlen, 2006; Miller, Campbell, & Pilkonis, 2007).Despite the highly disabling nature of the disorder with its major adverseimpact on the relationships of affected individuals with those around them,

including family, friends, and coworkers (Miller et al., 2007), the lack ofinformation on its prevalence and comorbidity in major subgroups of the


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184 PULAYANDGRANT

population creates gaps in our knowledge concerning etiology, economiccosts, planning of mental health services, and treatment.

Most of the research on NPD comorbidity has been conducted in clinicalsamples (George, Miklowitz, Richards, Simoneau, & Taylor, 2003; Mantere

et al., 2006; Oldham et al., 1995; Ronningstam, 1996; Skodol et al., 1995;Skodol, Oldham & Gallaher, 1999; Skodol, Stout, et al., 1999; Zimmerman,Rothschild, & Chelminski, 2005). In most of the clinical studies, no significantassociations were found between NPD and most mood and anxiety disorders,with the possible exception of bipolar disorder. Evidence linking NPD withsubstance use disorders, though strong in earlier clinical work (Ronningstam,1996), remains mixed when more recent clinical studies are considered (Fossatiet al., 2000; Skodol, Oldham, et al., 1999). By contrast, NPD has consistentlybeen shown to be associated with histrionic, antisocial, obsessivecompulsive,

and schizotypal personality disorders (Fossati et al., 2000; Marinangeli et al.,2000; Stuart et al., 1998), with mixed evidence for a relationship with border-line personality disorder (Grilo, Sanislow, & McGlashan, 2002; Marinangeliet al., 2000; Stuart et al., 1998; Zanarini et al., 1998).

Relative to clinical work on NPD, very little is known about disabilityand comorbidity of NPD in general population samples. Although preva-lence estimates of NPD are available from several early community surveys(Black, Noyes, Pfohl, Goldstein, & Blum, 1993; Ekselius, Tillfors, Furmark, &Fredrikson, 2001; Klein et al., 1995; Lenzenweger, Loranger, Korfine, & Neff,1997; Maier, Lichtermann, Minges, & Heun, 1992; Moldin, Rice, Erlenmeyer-

Kimling, & Squires-Wheeler, 1994; Reich, Yates, & Nduaguba, 1989; Zimmer-man & Coryell, 1989), these surveys were geographically restricted, in addi-tion to being limited by small sample sizes (Ns =229797). Others (Coid,Yang, Tyrer, Roberts, & Ullrich, 2006; Lenzenweger, Lane, Loranger, &Kessler, 2007; Samuels, Nestadt, Romanoski, Folstein, & McHugh, 1994)used statistical techniques to impute prevalence rates of NPD from smallsubsamples of individuals to larger general population samples, further limit-ing the precision of prevalence estimates.

Only one large epidemiologic survey (Torgersen, Kringlen, & Cramer,2001) conducted in Oslo, Norway, yielded prevalence estimates of basic

sociodemographic factors of NPD, reporting 0.8% prevalence of NPD in theirsample. Two more recent studies (Pulay, Goldstein, & Grant, 2011; Stin-son et al., 2008) using the Wave 2 National Epidemiologic Survey on Alco-hol and Related Conditions (NESARC; Grant, Kaplan, & Stinson, 2005)reported data on the prevalence, correlates, and comorbidity of NPD acrosssociodemographic characteristics and found a substantially larger rate of NPD(6.2%) in the U.S. general population. Stinson et al. (2008) reported highco-occurrence rates of NPD with substance use, mood, anxiety, and otherpersonality disorders and found independent associations between NPD and


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SEXANDRACEETHNICDIFFERENCES 185

bipolar I disorder, posttraumatic stress disorder, generalized anxiety disorder(GAD), borderline and schizotypal personality disorders. Their findings alsosuggested that a sex-specific comorbidity pattern exists in NPD, with menhaving greater odds to develop substance use disorders and histrionic and

obsessivecompulsive personality disorders and women being more prone toanxiety and mood disorders. Although this study provided valuable informa-tion on the psychiatric comorbidity of NPD, its scope was restricted to sexand did not analyze the comorbidity pattern from other important aspects,such as racialethnic differences.

Raceethnicity is an important determinant in psychiatric epidemiol-ogy; it influences both Axis I (Smith et al., 2006) and Axis II psychopathology(Alarcn, 2005). Despite its significance, no prior epidemiologic or clini-cal work has examined raceethnicity differences in NPD comorbidity. To

address this gap in our knowledge, we present comprehensive information onthe comorbidity of DSMIVNPD with Axis I and II disorders both by sex andraceethnicity using a large, nationally representative survey of the UnitedStates, the Wave 2 NESARC. The large sample size and high response rate ofthe Wave 2 NESARC allow for reliable, precise estimation of lifetime NPDcomorbidity, even for less frequent psychiatric conditions, especially amongthese important subgroups of the general population. By assessing an exten-sive set of DSMIVAxis I and II disorders, sociodemographic characteristicsand standardized, dimensional measures of mental functioning, the Wave 2

NESARC provides an excellent source of information on the comorbidity

pattern of NPD and its impact on mental functioning.

BACKGROUND OF THE WAVE 2 NESARC STUDY

The 20042005 Wave 2 NESARC is the second wave follow-up ofthe Wave 1 NESARC, conducted in 20012002 and described in detailelsewhere (Grant, Kaplan, et al., 2005; Grant, Moore, Shepard, & Kaplan,2003). The Wave 1 NESARC provided a representative sample of the civil-ian population of the United States ages 18 years and older that resides in

households and group quarters. Face-to-face interviews were conducted with43,093 respondents, oversampling Blacks, Hispanics, and young adults 18 to24 years old, with an overall response rate of 81.0%.

Attempts were made in Wave 2 to conduct a second round of face-to-face interviews with all Wave 1 respondents. Respondents were excludedfrom the Wave 2 if they were mentally or physically impaired, deported, oron active military duty over the entire follow-up period. The Wave 2 had aresponse rate of 86.7%, reflecting 34,653 completed interviews with a cumu-lative response rate at Wave 2 of 70.2%. As in Wave 1, the Wave 2 NESARC


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186 PULAYANDGRANT

data were weighted to reflect design characteristics of the survey and accountfor oversampling.

Diagnoses of NPD were made at Wave 2 using the Alcohol Use Dis-order and Associated Disabilities Interview ScheduleDSMIVVersion

(AUDADISIV; Grant, Dawson, & Hasin, 2001, 2004), a fully structureddiagnostic instrument designed for use by experienced nonclinician inter-viewers. Because the diagnosis of NPD requires evaluation of long-term pat-terns of functioning (American Psychiatric Association, 1994), all NESARCrespondents were asked a series of NPD symptom questions about how theyfelt or acted most of the time throughout their lives, regardless of the situationor whom they were with. Respondents were also instructed to exclude symp-toms that occurred only when they were depressed, manic, anxious, drink-ing heavily, using medicines or drugs, experiencing withdrawal symptoms, or

physically ill. NPD symptom items (n=

18), representing NPD criteria, weresimilar to those in the Structured Clinical Interview for DSMIVPersonalityDisorders (First, Gibbon, Spitzer, Williams, & Benjamin, 1997), the Inter-national Personality Disorder Examination (Loranger, 1999), and the Diag-nostic Interview for DSMIVPersonality Disorders (Zanarini, Frankenburg,Sickel, & Yong, 1996). Reliability of the NPD diagnosis and symptom scaleswere good (=0.70, 0.72; Ruan et al., 2008).

Wave 2 AUDADIS-IV measures of substance use (alcohol and drug-specific abuse and dependence and nicotine dependence), mood (majordepressive disorder [MDD], dysthymia, bipolar I, and bipolar II), and anxiety

(panic disorder with and without agoraphobia, social phobia, specific phobia,and GAD) disorders were identical to those measured in Wave 1, whereasposttraumatic stress disorder was assessed only in Wave 2. For this study, alldisorders were assessed on a lifetime basis, occurring over the life course asassessed in both Wave 1 and Wave 2.

A comprehensive set of questions covered DSMIVcriteria for alcoholand drug-specific abuse and dependence, including sedatives, tranquilizers,opioids other than heroin, cannabis, cocaine or crack, stimulants, hallucino-gens, inhalants and solvents, heroin, and other illicit drugs. Consistent withWave 1 diagnoses, Wave 2 12-month abuse required one of more of four

abuse criteria and dependence required three or more of seven dependencecriteria to be met in any 1-year period covered by Waves 1 and 2 surveys.Drug-specific abuse and dependence were aggregated in this study to yielddiagnoses of any drug abuse and any drug dependence.

The reliability and validity of AUDADIS-IV alcohol and drug diagno-ses are documented in clinical and general population samples (Grant, Daw-son, et al., 2003; Grant, Harford, Dawson, Chou, & Pickering, 1995; Hasin,Carpenter, McCloud, Smith, & Grant, 1997; Hasin & Paykin, 1999; Hasinet al., 2003; Ruan et al., 2008), including in the World Health Organization/


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National Institutes of Health International Study on Reliability and Valid-ity (Chatterji et al., 1997; Hasin, Grant, et al., 1997; Vrasti et al., 1998),in which clinical reappraisals documented good validity (Canino et al.,1999; Cottler et al., 1997).

Mood, anxiety, and personality disorders only included DSMIVprimarydisorders excluding substance-induced disorders and those caused by generalmedical conditions. Diagnoses of MDD also ruled out bereavement, whereasdiagnoses of personality disorders also excluded symptoms that only occurredwhen respondents were depressed, manic, or anxious. Testretest reliabilityand validity for AUDADIS-IV mood, anxiety, and personality disorder diag-noses in the general population and clinical samples were fair to excellent(Grant et al., 2006; Grant, Hasin, Blanco, et al., 2005; Grant, Hasin, Stinson,et al., 2005; Grant, Hasin, et al., 2004; Grant, Stinson, et al., 2005; Hasin,Goodwin, Stinson, & Grant, 2005; Ruan et al., 2008; Stinson et al., 2007).

Disability was derived from the Short Form-12 Health Survey, version 2(SF-12v2; Gandek et al., 1998). The SF-12v2 scores measures impairment inthree dimensions of mental functioning: social functioning, role emotionalfunctioning, and mental health. Standard norm-based scoring techniqueswere used to transform each score ranging from 0 to 100 to achieve a meanof 50 and a standard deviation of 10 in the U.S. general population. Lowerscores indicate greater disability.

NOVEL FINDINGS FROM THE WAVE 2 NESARC STUDY

As noted previously, data on raceethnic differences in the comorbid-ity of NPD have not been reported. The nationally representative Wave 2

NESARC study provided an excellent opportunity to examine psychiatriccomorbidity of NPD in the general adult population. In this section, wedescribe the statistical procedures used in these analyses and present our find-ings on the sex- and race-specific co-occurrence and association of NPD withDSMIVAxis I and II disorders and mental disability.

Statistical Procedure

Weighted frequencies and cross-tabulations were computed to calculate(a) lifetime prevalences of NPD among respondents with other psychiatric disor-ders and (b) prevalences of other psychiatric disorders among respondents with

NPD. Weighted mean SF-12v2 scores were computed to assess mental disabil-ity. Pairwise tstatistics were used to test sex and raceethnic differences in ratesof co-occurrence of NPD with other psychiatric disorders. Because of sample sizelimitations, detailed analyses among raceethnic groups were carried out onlyfor Whites, Blacks, and Hispanics (excluding Asians and Native Americans).


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Odds ratios of NPD and other DSMIVdisorders were calculated by using seriesof multivariable logistic regression models. Relationships between NPD andthe dimensions of mental disability measures were assessed with multiple lin-ear regression analyses. All logistic and linear regression models controlled for

sociodemographic characteristics and comorbid psychiatric disorders by usingSoftware for Survey Data Analysis (Research Triangle Institute, 2006).

Co-Occurrence of Lifetime DSMIVNPD and Lifetime Axis Iand II Psychiatric Disorders

Co-occurrences of NPD with other psychiatric disorders by sex and byraceethnicity are shown in Tables 11.1 and 11.2, respectively. Prevalences ofsubstance use, mood, anxiety, and other personality disorders among respon-

dents with NPD were 64.5%, 49.1%, 54.6%, and 62.7%, respectively. Ratesof substance use disorders were higher among men than women with NPD,whereas rates of MDD and anxiety disorders except social phobia were higheramong women with NPD than men with NPD. Men with NPD were alsomore likely than women to have antisocial personality disorder, whereaswomen with NPD were more likely than men to have paranoid, avoidant, andborderline personality disorders. With regard to raceethnicity, White respon-dents with NPD had higher rates of substance use disorders than Blacks andHispanics, except for drug dependence, whereas rates of alcohol dependencewere higher among Whites than Blacks. Furthermore, Whites with NPD had

higher rates of MDD and GAD than Blacks. Among Axis II disorders, schizo-typal personality disorder was more prevalent among Blacks than Whites andHispanics with NPD, rates of avoidant personality disorder was significantlyhigher among Whites than Blacks, whereas rates of obsessivecompulsive per-sonality disorder were higher among Whites than Blacks and Hispanics.

In the total sample, prevalence rates of NPD among respondents withlifetime substance use, mood, and anxiety disorders were 8.7%, 11.8%, and11.4%. Rates of NPD were significantly higher among men than women withall Axis I disorders except dysthymia, bipolar II disorder, and panic disorderwith agoraphobia. Rates of NPD were also higher among men with histri-

onic, borderline, and obsessivecompulsive personality disorders relative towomen with these disorders.

With regard to raceethnicity, the prevalences of NPD among respon-dents with all substance use and mood, anxiety, and personality disorders,except for histrionic, avoidant, and dependent personality disorders, werehigher among Blacks than Whites. Rates of NPD were higher among Blackswith alcohol dependence, nicotine dependence, MDD, specific phobia, andschizotypal, schizoid, and obsessivecompulsive personality disorders comparedwith Hispanics. Prevalences of NPD were also higher among Hispanics with


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TABLE11.1

Co-O

ccurrenceRatesofLifetimeDSMIVNarcissisticPersonalityDisorder(NPD)

andAxisIandIILife

timePsychiatricDisordersb

ySex

Prevalenceofotherpsychiatricdisorders

amongresponde

ntswithNPD

PrevalenceofNPDamongresp

ondents

withotherpsychiatricdisorders

Psychiatricdisorder

Total%(SE)

Men%(S

E)

Women%(SE)

Tota

l%(SE)

Men%(SE)

Wo

men%(SE)

Anysubstanceusedisorder

64.5(1.35)

73.4(1.7

2)

51.1(1.94)a

8.7(0.34)

9.9(0.45)

6.9(0.41)a

Anysubstanceabuse

35.5(1.43)

43.6(1.8

8)

23.4(1.66)a

8.2(0.39)

9.2(0.52)

6.4(0.52)a

Anysubstancedependence

50.5(1.45)

56.4(1.9

7)

41.7(2.12)a

10.0(0.45)

11.7(0.60)

7.8(0.52)a

Anyalcoholusedisorder

51.4(1.43)

62.7(1.7

6)

34.4(1.76)a

9.0(0.36)

10.0(0.45)

7.2(0.46)a

Alcoholabuse

20.4(1.08)

25.4(1.5

5)

12.9(1.04)a

6.4(0.36)

7.2(0.49)

4.8(0.44)a

Alcoholdependence

30.9(1.25)

37.3(1.7

5)

21.5(1.68)a

12.4(0.61)

13.6(0.77)

10.2(0.87)a

Anydrugusedisorder

26.2(1.27)

31.7(1.6

3)

17.9(1.71)a

13.4(0.68)

15.3(0.87)

10.2(1.04)a

Anydrugabuse

19.7(1.11)

24.3(1.4

5)

12.8(1.52)a

11.9(0.69)

13.4(0.93)

8.9(1.08)a

Anydrugdependence

11.8(0.94)

14.4(1.3

0)

7.9(1.06)a

21.9(1.63)

26.0(2.14)

15.4(2.06)a

Nicotinedependence

35.8(1.39)

39.5(1.8

3)

30.2(1.86)a

9.5(0.45)

11.6(0.67)

7.1(0.49)a

Anymooddisorder

49.1(1.36)

44.2(1.8

0)

56.5(1.81)a

11.8(0.47)

17.0(0.84)

8.7(0.45)a

Majordepressivedisorder

20.3(1.03)

17.4(1.3

3)

24.6(1.39)a

7.6(0.42)

12.0(0.88)

5.5(0.40)a

Dysthymia

3.9(0.42)

3.2(0.5

7)

5.0(0.69)

7.1(0.75)

10.6(1.82)

5.4(0.74)

BipolarI

20.0(1.05)

18.5(1.4

6)

22.2(1.48)

23.8(1.31)

29.5(2.17)

19.1(1.41)a

BipolarII

4.4(0.53)

3.4(0.6

9)

6.0(0.79)

16.1(1.73)

18.3(3.25)

14.6(1.86)

Anyanxietydisorder

54.6(1.33)

46.6(1.9

9)

66.4(1.89)a

11.4(0.44)

16.5(0.81)

8.6(0.44)a

Panicwithagoraphobia

5.8(0.67)

3.3(0.8

5)

9.7(1.18)a

19.2(2.11)

22.0(4.90)

18.1(2.22)

Panicwithoutagoraphobia

11.4(0.80)

9.1(1.0

0)

14.8(1.37)a

12.0(0.91)

17.5(1.92)

9.3(0.90)a

Socialphobia

15.1(1.02)

13.0(1.2

9)

18.4(1.70)

13.4(0.87)

16.9(1.62)

11.0(1.03)a

(continues)


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190 PULAYANDGRANT

TABLE11.1

Co-O

ccurrenceRatesofLifetimeDSMIVNarcissisticPersonalityDisorder(NPD)

andAxisIandIILifetimePsychiatricDisordersbySex

(Continued)

Prevalenceofotherpsychiatricdisorders

amongresponde

ntswithNPD

PrevalenceofNPDamongresp

ondents

withotherpsychiatricdisorders

Psychiatricdisorder

Total%(SE)

Men%(SE)

Women%(SE)

Tota

l%(SE)

Men%(SE)

Women%(SE)

Specificphobia

27.5(1.29)

20.5(1.6

7)

38.0(1.96)a

11.1(0.56)

15.3(1.18)

9.2(0.56)a

Generalizedanxiety

19.7(1.12)

14.5(1.2

8)

27.6(1.88)a

15.9(0.92)

22.6(1.89)

1

2.9(0.95)a

Posttraumaticstress

18.0(0.99)

13.5(1.3

0)

24.7(1.68)a

17.1(1.06)

24.9(2.42)

1

3.7(1.05)a

Anyotherpersonalitydisorder

62.7(1.36)

60.3(1.8

0)

66.3(1.90)

20.2(0.66)

23.1(0.92)

1

7.3(0.81)a

AnyClusterA

38.0(1.36)

35.6(1.6

9)

41.5(2.03)

26.2(1.05)

30.8(1.58)

2

2.1(1.25)a

Paranoid

14.9(0.97)

12.9(1.2

1)

17.9(1.44)a

21.8(1.25)

27.7(2.42)

1

7.7(1.35)a

Schizoid

8.7(0.73)

8.1(1.0

1)

9.7(1.11)

17.6(1.42)

20.4(2.43)

1

5.0(1.67)

Schizotypal

27.3(1.16)

25.6(1.5

2)

29.8(1.77)

42.8(1.69)

46.0(2.48)

3

9.2(2.31)

AnyotherClusterB

45.0(1.38)

43.6(1.6

9)

47.1(2.08)

28.4(0.99)

30.1(1.35)

2

6.4(1.30)

Antisocial

11.6(0.92)

14.0(1.2

6)

8.1(1.10)a

19.0(1.35)

18.5(1.53)

2

0.3(2.50)

Borderline

36.8(1.31)

33.8(1.6

7)

41.3(1.98)a

38.9(1.47)

47.8(2.28)

3

1.7(1.67)a

Histrionic

9.6(0.84)

10.0(1.1

2)

9.0(1.05)

33.1(2.25)

41.7(3.39)

2

4.7(2.58)a

AnyClusterC

24.6(1.29)

23.4(1.6

5)

26.3(1.70)

16.0(0.80)

19.7(1.34)

1

2.8(0.91)a

Avoidant

6.8(0.70)

5.2(0.8

7)

9.2(1.22)a

18.2(1.73)

21.6(3.23)

1

6.1(1.91)

Dependent

1.7(0.42)

1.5(0.6

1)

2.0(0.51)

25.4(4.94)

37.8(9.59)

1

8.5(4.52)

Obsessivecompulsive

21.7(1.24)

21.9(1.6

1)

21.4(1.57)

16.5(0.89)

20.7(1.47)

1

2.6(1.01)a

Note.

DSMIV=D

iagnosticandStatisticalManualofMentalDisorders(4the

d.).

aPrevalenceratesforwomenaresignificantlydifferent(p

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11. Sex and race—Ethnic differences in psychiatric comorbidity of narcissistic