Categorical and dimensional models of pathological narcissism: the case of Mr. Jameson.

Narcissistic pathology is assessed in the diagnostic manuals as a categorical construct characterized by cognitive, emotional, and behavioral indicators of grandiosity. This framework ignores the complexities of the construct that also include vulnerability. We suggest that assessing grandiosity and vulnerability as dimensional, interactive components provides the greatest utility when working with narcissistic patients. We describe a patient who presents as fragile, shy, and sensitive, but also has vivid fantasies about his superiority. While he does not meet the DSM-IV criteria for Narcissistic Personality Disorder, we highlight how anxiety, shame, and submissiveness co-occur with grandiosity, which maintain a narcissistic personality organization characterized by severe deficits in self-esteem regulation. We encourage the integration of dimensional assessment into the diagnosis of narcissistic pathology.