Health Psychology Review
ISSN: 1743-7199 (Print) 1743-7202 (Online) Journal homepage: http://www.tandfonline.com/loi/rhpr20
Narcissism and stress-reactivity: a biobehavioural
health perspective
Sulamunn R. M. Coleman, Aaron L. Pincus & Joshua M. Smyth
To cite this article: Sulamunn R. M. Coleman, Aaron L. Pincus & Joshua M. Smyth (2018):
Narcissism and stress-reactivity: a biobehavioural health perspective, Health Psychology Review,
DOI: 10.1080/17437199.2018.1547118
To link to this article: https://doi.org/10.1080/17437199.2018.1547118
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HEALTH PSYCHOLOGY REVIEW
https://doi.org/10.1080/17437199.2018.1547118
Narcissism and stress-reactivity: a biobehavioural health
perspective
Sulamunn R. M. Coleman
a
, Aaron L. Pincusb and Joshua M. Smyth
a
a
Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA, USA; bDepartment of
Psychology, The Pennsylvania State University, University Park, PA, USA
ABSTRACT
ARTICLE HISTORY
From a perspective broadly informed by Stress and Coping Theory, this
review examined whether theoretically distinct and important dimensions
of narcissism (grandiosity and vulnerability) associate with health-related
stress-reactivity. Literature searches were conducted and articles were
included if they contained a validated baseline assessment of narcissism,
a stressor, and a within-person assessment of stress-reactivity (i.e., a
baseline and post-stress assessment of a health-related psychological,
biological, or behavioural process). Additionally, narcissism measures had
to be systematically categorised as assessing grandiosity or vulnerability
(see Grijalva, E., Newman, D. A., Tay, L., Donnellan, M. B., Harms, P. D.,
Robins, R. W., & Yan, T. (2015). Gender differences in narcissism: A metaanalytic review. Psychological Bulletin, 141(2), 261–310. doi:10.1037/
a0038231), and narcissism dimensions had to be assessed independently
of other constructs. Findings were narratively synthesised within three
broad dimensions of stress-reactivity (psychological, biological, and
behavioural). Overall, there appear to be relatively consistent patterns that
grandiosity and vulnerability are related to altered stress-reactivity.
Additionally, grandiosity and vulnerability may differentially influence
stress-reactivity depending on the type of stressor and/or indicator of
stress-reactivity (e.g., under certain conditions, grandiosity may confer
some level of resilience). This review highlights important theoretical and
empirical gaps in the emerging narcissism and health literature.
Furthermore, this review may help inform methodological considerations
for future research, and may also point to physical health outcomes that
could conceivably be affected by narcissism over time (e.g., overweight/
obesity, cardiovascular disease, HIV/AIDS).
Received 2 March 2018
Accepted 8 November 2018
KEYWORDS
Narcissism; grandiosity;
vulnerability; stress; coping;
health
Narcissism is a complex, stereotypically negative aspect of personality. Despite an extensive history in
clinical literature (Levy, Ellison, & Reynoso, 2011), narcissism has only recently gained greater interest
in stress and health research, and appears to be associated with a variety of health-related stress
responses (i.e., changes in psychological, biological, and behavioural processes in response to threatening stimuli; Konrath & Bonadonna, 2014). Evidence has demonstrated that individuals higher in
narcissism may report more frequent and varied stressors in daily life (McCullough, Emmons, Kilpatrick, & Mooney, 2003), which suggests such individuals may be at increased risk for chronic stress.
Although prevalence estimates appear to vary (e.g., ranging from 0.0% to 6.3%; Cain, Pincus, &
Ansell, 2008; Mattia & Zimmerman, 2001; Pincus & Lukowitsky, 2010), some evidence suggests narcissism may be prevalent in industrialised nations (e.g., 6.3% of the U.S. population may meet diagnostic
criteria for Narcissistic Personality Disorder; Stinson et al., 2008), where diseases associated with
CONTACT Sulamunn R. M. Coleman
sulamunn.coleman@uvm.edu
© 2018 Informa UK Limited, trading as Taylor & Francis Group
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S. R. COLEMAN ET AL.
chronic stress (e.g., heart disease) are the leading causes of death. It is therefore important to understand how narcissism influences health-related stress-reactivity.
As research examining whether narcissism represents a health-related aspect of personality
accumulates, associations between narcissism and stress-reactivity appear to be complex and somewhat inconsistent. For example, some studies have demonstrated associations between narcissism
and health-related sympathetic and parasympathetic responses to psychosocial stress (e.g., Edelstein,
Yim, & Quas, 2010; Kelsey, Ornduff, McCann, & Reiff, 2001; Sommer, Kirkland, Newman, Estrella, &
Andreassi, 2009), whereas other studies have found no correlation between narcissism and autonomic arousal (e.g., Dane, Jonason, & McCaffrey, 2018; Sylvers, Brubaker, Alden, Brennan, & Lilienfeld,
2008). This is likely due in part to a relatively limited number of studies in an emerging body of
research. However, it is also clear that narcissism and stress have been inconsistently defined and
measured across decades of research (see Pincus & Lukowitsky, 2010; Smyth, Zawadzki, & Gerin,
2013, respectively, for some discussion). In particular, debate over the identification, operationalisation, and assessment of the primary components of narcissism is ongoing, which may further account
for some of the apparent discrepancy in the related stress and health literature. Moreover, prominent
contemporary theories of narcissism postulate that different types of stressors (e.g., interpersonal
rejection vs. achievement failure), related aspects of personality (e.g., extraversion, neuroticism,
antagonism), and/or fixed characteristics of individuals (e.g., gender/sex) could further explain associations between narcissism and stress responses; however, such factors are often not examined in
individual studies and have not been reviewed more generally.
Importantly, there have been many calls for research to help clarify the primary dimensions of narcissism and determine how such dimensions relate to relevant intra- and interpersonal processes.
Although this review may provide some preliminary insight into how narcissism influences healthrelated stress-reactivity, it is not our primary purpose to use this information to clarify the dimensions
of narcissism or add to the ongoing debate over the operationalisation and assessment of narcissism
(for comprehensive reviews addressing these issues, see Krizan & Herlache, 2018; Morf, 2006; Morf &
Rhodewalt, 2001; Pincus & Lukowitsky, 2010; Pincus, Roche, & Good, 2015; Wright & Edershile, 2018).
Rather, this review offers an interdisciplinary perspective broadly informed by Stress and Coping
Theory (Lazarus & Folkman, 1984) to provide an overview of how narcissism has been associated
with health-related stress-reactivity. By clarifying and elaborating on how widely accepted dimensions of narcissism (i.e., grandiosity and vulnerability) have associated with various stress responses,
this review seeks to identify theoretical and empirical gaps in the existing literature that may help
inform methodological considerations for stress and health researchers who may be interested in
studying narcissism. Furthermore, this review may help to identify physical health outcomes that
may be conceivably affected by narcissism over time (e.g., overweight/obesity, cardiovascular
disease, HIV/AIDS). Additionally, by providing preliminary insight into how grandiosity and vulnerability have been associated with health-related stress-reactivity, this review may help to inform prominent, contemporary theories of narcissism.
Narcissism
Individuals high in narcissism prioritize their needs and goals over those of others, have an inflated
sense of self-importance, and believe they are entitled to especially favourable treatment (Krizan &
Herlache, 2018). More generally, narcissism encompasses two broad dimensions of personality:
grandiosity and vulnerability. Grandiosity is characterised by an overriding need for recognition and
admiration to maintain and enhance the inflated sense of self-importance, whereas vulnerability is
characterised by difficulty regulating self-concept, emotion, and behaviour when grandiosity is threatened (Miller, Lynam, Hyatt, & Campbell, 2017; Pincus & Lukowitsky, 2010; Pincus et al., 2015). There
are many assessments of narcissism, including clinical interviews and self-report measures, and it is
generally accepted that the different assessments capture different dimensions of narcissism. For
example, assessments of grandiosity such as the Narcissistic Personality Inventory (Raskin & Hall,
HEALTH PSYCHOLOGY REVIEW
3
1981) tend to capture themes of extraversion and exhibitionism, manipulative and exploitive tendencies, and/or a preoccupation with social status and associated fantasies of recognition and
admiration. On the other hand, assessments of vulnerability, such as the Hypersensitive Narcissism
Scale (Hendin & Cheek, 1997) and the vulnerability scale of the Pathological Narcissism Inventory
(Pincus et al., 2009) generally capture themes of neuroticism, interpersonal hypervigilance, avoidance
and/or devaluation of sources of criticism, and shame over having needs for recognition and admiration in the first place. Importantly, narcissism has been inconsistently defined across decades of
research. For example, the terms ‘overt-’ and ‘covert-narcissism’ have been applied to grandiosity
and vulnerability respectively, when in fact, both grandiosity and vulnerability may involve overt
(i.e., behavioural) and covert expression (i.e., intra-psychic) (Pincus, 2013). Precision of terminology
is critical in evaluating existing literature, particularly with respect to narcissism, as each dimension
exhibits differential patterns of association with other health-relevant aspects of personality (e.g.,
grandiosity tends to be positively correlated with extraversion and negatively correlated with neuroticism, and vulnerability tends to exhibit the opposite pattern of correlations; Miller & Maples, 2011).
As such, it is important to clearly differentiate between assessments of grandiosity and vulnerability
in an examination of how narcissism associates with health-related stress-reactivity.
Complicating the matter, the structure and measurement of narcissism (and components thereof)
is a subject of ongoing debate. Some measures of narcissism, such as the Narcissistic Personality
Inventory (NPI) and the grandiosity scale of the Pathological Narcissism Inventory (PNI), have had
their construct validity called into question and have thus become the focus of considerable controversy (Ackerman et al., 2011; Edershile, Simms, & Wright, 2018; Miller, Lynam, & Campbell, 2016). Generally, the NPI and PNI are thought to capture different variants of grandiosity (i.e., ‘normal’ vs.
‘pathological’ respectively), and researchers have been advised to use caution when discussing
results pertaining to either of these scales. Furthermore, although researchers widely agree that
the various measures of narcissism capture different dimensions (and potentially variants of dimensions), investigators from different fields tend to disagree over the higher order factor structure of
narcissism under which to categorise existing measures. For example, some investigators endorse
a three-factor solution to represent the primary dimensions of narcissism and propose that existing
measures could be sorted according to the Big Five traits extraversion (e.g., the ‘grandiose exhibitionism’ subscale of the Narcissistic Personality Inventory), neuroticism (e.g., Hypersensitive Narcissism
Scale; Hendin & Cheek, 1997), and [dis]agreeableness (the grandiosity and vulnerability scales of
the Pathological Narcissism Inventory; Pincus et al., 2009; Wright & Edershile, 2018). Other investigators endorse a two-dimensional solution and propose sorting measures according to the
broader dimensions of grandiosity and vulnerability (Grijalva et al., 2015; Pincus & Lukowitsky, 2010).
One could speculate that such discrepancy over the structure and measurement of (dimensions
of) narcissism may at least partially explain why narcissism appears to inconsistently associate with
stress-reactivity. In the current review, it is important to determine what dimension(s) of narcissism
were assessed in prior studies to carefully examine how each dimension has independently associated with various stress responses. To this end, the current review categorises existing narcissism
measures along the broader dimensions of grandiosity and vulnerability using the systematic categorisation contained in Grijalva et al. (2015; Table 5, p. 272). Importantly, this categorisation has been
successfully utilised to identify and exclude measures of vulnerability in a recent review and metaanalysis of associations between grandiosity and self-enhancement (Grijalva & Zhang, 2016). Furthermore, although Wright and Edershile (2018) provide a potentially useful categorisation of existing
narcissism measures along Big Five traits, their list of measures is not as extensive as the list provided
in Grijalva et al. (2015). Thus, the categorisation contained in Grijalva et al. (2015) allows for the
inclusion of a greater number of studies in this review. Further still, the categorisation provided
from Wright and Edershile (2018) allows for some measures of narcissism to be categorised into
more than one dimension. For example, they categorised the grandiosity scale of the Pathological
Narcissism Inventory as capturing themes of disagreeableness at the primary level, but also categorised the scale as capturing themes of extraversion and neuroticism at the secondary level. This
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S. R. COLEMAN ET AL.
type of multilevel categorisation may prove to complicate the current examination and discussion of
how dimensions of narcissism have been associated with health-related stress responses.
Stress-reactivity
Like narcissism, stress-reactivity is a complex construct. Despite decades of research, stress (and, consequently, stress-reactivity) remains difficult to clearly label and measure (for a review, see Smyth
et al., 2013). According to Stress and Coping Theory (see Lazarus & Folkman, 1984, for seminal
work), stress involves an initial two-stage appraisal process during which individuals first evaluate
the potential for threat, harm, or loss associated with a stimulus or stressor, then evaluate their personal resources for managing the stimulus. In accordance with this view, a ‘stressor’ is thus any stimulus (real or imagined) that one appraises as having (1) the potential to cause threat, harm, or loss to an
individual, and (2) exceeds the available resources required to readily manage the challenge. Stressreactivity is the resulting coordinated set of psychological, biological, and behavioural responses to
the stressor that, ideally, facilitate one’s ability to cope with (or manage) the stressor.
This broad framework derived from stress and coping literatures is used in this review to take into
consideration additional processes that may not be intuitively stress-related. For example, in addition
to changes in perceived stress, psychological stress responses may involve changes in affect (e.g.,
increased anxiety in anticipation of an unavoidable noise blast) or self-concept (e.g., social exclusion
may catalyse decreases in self-esteem; Williams, 2007). Such responses are adaptive in that they alert
the individual to changes in the environment and prompt behavioural adjustments necessary for
coping. However, stress responses may become detrimental to health when they deviate from
normal ranges. For example, greater affective reactivity has been associated with increased risk of
reporting a chronic disease over time (Piazza, Charles, Sliwinski, Mogle, & Almeida, 2012), and both
over- and under-reactive biological responses (e.g., cardiovascular, endocrine) have been associated
with risk for obesity, cardiovascular disease, and poor immune response (Carroll, Lovallo, & Phillips,
2009; Chida & Steptoe, 2010; Phillips, Ginty, & Hughes, 2013). Importantly, a variety of stressors
have the potential to threaten needs for recognition and admiration, including psychosocial stressors
such as social evaluation (Dickerson & Kemeny, 2004) or interpersonal rejection (Williams, 2007, 2009),
or physical stressors (e.g., physical exertion, injury) that confront physical limitations. Given that narcissism encompasses an inflated sense of self-importance, an overriding need for recognition and
admiration, and self-regulatory deficits when needs for recognition and admiration are threatened
(or frustrated), one may speculate that narcissism predicts a variety of stress responses that
deviate from normal ranges. However, there appears to be some contradictory evidence regarding
relationships between narcissism and self-reported coping responses that helps to underscore the
need to clarify and elaborate on associations between narcissism and stress-reactivity.
Cross-sectional evidence has demonstrated that grandiosity and vulnerability may differentially
influence coping, which suggests narcissism dimensions may differentially associate with healthrelated stress responses. In one study, grandiosity was positively correlated with reported use of
task-oriented coping, planful problem solving, self-controlling, and positive reappraisal, all of
which are considered adaptive coping strategies (Birkás, Gács, & Csathó, 2016). Additionally, grandiosity was negatively correlated with avoidance, distancing, and escape-avoidance (i.e., wishful thinking to escape or avoid a problem), which are considered maladaptive coping strategies. In another
study, vulnerability was positively correlated with reported use of denial and behavioural disengagement (e.g., quitting when a task becomes too stressful), both of which are generally considered maladaptive coping strategies (Fernie, Fung, & Nikčević, 2016). In a third study, grandiosity was negatively
correlated with perceived stress and positively correlated with reported coping flexibility (i.e., the
ability to monitor and discontinue ineffective coping, and adopt alternative coping methods), and
vulnerability exhibited the opposite pattern of correlations (Ng, Cheung, & Tan, 2014). Together,
these findings suggest that despite being viewed as a stereotypically negative aspect of personality,
grandiosity may catalyse stress responses associated with adaptive coping, and vulnerability may be
HEALTH PSYCHOLOGY REVIEW
5
primarily associated with maladaptive stress responses. As such, a careful examination of how grandiosity and vulnerability have been associated with stress-reactivity is warranted. In particular, it is
important to carefully review evidence from studies utilising within-person methods to index
stress-related changes in health processes. A careful examination of such evidence is an important
step towards identifying physical health outcomes that may be conceivably affected by narcissism
over time, and can also help guide future research in this domain.
The current review
The purpose of this review is to provide an overview of research examining associations between narcissism and stress-reactivity in an effort to identify theoretical and empirical gaps in the existing literature that may help inform future research. To this purpose, the primary objective is to examine how
theoretically distinct dimensions of narcissism (i.e., grandiosity and vulnerability) have been associated
with various stress responses, including psychological, biological, and behavioural responses associated
with physical health outcomes. This review focuses specifically on evidence from studies utilising
within-person methods. Prior reviews have examined how narcissism associates with specific processes
very peripherally related to stress, such as self-esteem (Baumeister, Bushman, & Campbell, 2000; Bosson
et al., 2008), aggression (Baumeister et al., 2000; Rasmussen, 2016), and sexual behaviour (Baumeister,
Catanese, & Wallace, 2002), and these reviews incorporated evidence from studies utilising betweenperson methods. A strength of the current review is its focus on studies utilising within-person
methods that allow for greater causal inferences about how narcissism dimensions may influence
stress-reactivity without having to rely on the assumption of successful experimental randomisation.
Given the breadth of this topic, including the heterogeneity of study designs, sample characteristics, assessments of narcissism (and controversy/debate over the operationalisation and assessment
of narcissism), stressor types, and other ‘outcomes’, the decision was made to conduct a narrative
review rather than a more formal meta-analysis or Cochrane style review. For example, as noted
above, the Narcissistic Personality Inventory and Pathological Narcissism Inventory grandiosity
scale are considered rather controversial assessments of grandiosity, and their construct validity
has become the subject of relatively intense debate (Ackerman et al., 2011; Edershile et al., 2018;
Miller et al., 2016). Because the NPI and PNI are considered to assess normal and pathological variants
of grandiosity respectively, overall effect sizes derived from aggregating studies using the NPI and
PNI could be misleading. Furthermore, some investigators examine associations between stress
responses and specific facets of narcissism dimensions (e.g., the ‘leadership/authority’ subscale of
the NPI, which constitutes a facet of grandiosity). More partitioning of narcissism dimensions into
specific facets would further reduce the number of studies to include in an empirical review, and
again, combining these results to examine overall effect sizes could be misleading. By soliciting
unpublished materials, it may be possible to acquire sufficient data to conduct an empirical review
on associations between narcissism dimensions and a specific stress response (e.g., changes in
anger or aggression). However, the results of such a review would be overly narrow, largely redundant with existing reviews (e.g., Rasmussen, 2016), and thus, potentially less informative to stress
and health researchers. For these reasons, a narrative review seems optimal for an initial, critical
examination of associations between narcissism and stress-reactivity in order to identify theoretical
and empirical gaps in the literature, offer preliminary insight into how narcissism may influence physical health outcomes over time, and make practical recommendations for future research.
Method
Eligibility criteria
A literature search was conducted using the electronic databases PsycINFO, PubMed, and Web of
Science, and the search engine Google Scholar. Search terms included the keywords narcissism
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S. R. COLEMAN ET AL.
AND (stress OR threat OR strain OR reactivity OR response). Functional search terms (i.e., ‘narciss*’,
‘stress*’, ‘threat*’, ‘strain*’, ‘react*’, and ‘respons*’) were used in all three electronic databases in
order to broaden the search (e.g., to produce results for trait narcissism and Narcissistic Personality
Disorder, ‘stress’ and ‘stressors’, ‘threat’ and ‘threatened’, etc.). In Google Scholar, using full words
(e.g., ‘narcissism’) automatically returns results with similar word stems (e.g., ‘narcissist’, ‘narcissistic’);
as such, functional search terms were not included in Google Scholar. After excluding books, dissertations, and theses, limiting study methodology to human empirical, quantitative, longitudinal, or
prospective studies, and restricting search results to articles available in English, 871 articles were
identified for screening. Duplicates (117) and incomplete texts (7) were removed. The remaining
full-text articles (747 retained) were screened for eligibility. Articles were included in the review if
they contained a validated, baseline measure of narcissism (298 retained), a stressor (i.e., a stimulus
that may be reasonably appraised as a potential source of threat, harm, or loss: Lazarus & Folkman,
1984) (118 retained), and a baseline and post-stress assessment of a health-related psychological, biological, or behavioural process (36 retained). In order to determine the independent influence of narcissism on stress-reactivity, narcissism had to be assessed independently of other constructs and not
combined with other measures to form a composite (34 retained). For example, one study was
excluded because it combined the narcissism and antisocial subscales of the MCMI-II to form a psychopathy composite (Chase, O’leary, & Heyman, 2001), and another study was excluded because it
combined the NPI with other measures to form a composite measure of ‘leader status’ (Akinola &
Mendes, 2014). Finally, the measure of narcissism had to be categorised in Grijalva et al. (2015) in
order to determine whether grandiosity or vulnerability was assessed. Subsequently, 25 articles
were retained, and the reference lists of these articles were also screened for additional publications.
In total, 29 articles were included in the review.
Organisation of results section and summary tables
The results are divided into two main sections. The first section presents associations between grandiosity and stress responses within each domain of stress-reactivity beginning with psychological reactivity, followed by biological reactivity, and ending with behavioural reactivity. The second section
presents associations between vulnerability and stress responses following the same structure. The
corresponding summary tables are organised alphabetically by ‘Authors’ and articles appear in
more than one table if more than one dimension of stress-reactivity was examined. For example,
Edelstein et al. (2010) appear in Tables 1 and 2 because they examined associations between grandiosity and changes in (1) affect and (2) cortisol (i.e., a hormonal marker of stress-reactivity). Additionally, each table includes columns for ‘Study Design’, ‘Sample Characteristics’ including age and sex,
‘Grandiosity [or Vulnerability] Measure’, ‘Stressor/Assessment of Stress-Reactivity’, and ‘Findings’. In
addition to examining how grandiosity and vulnerability have generally associated with stress-reactivity, we examine additional variables (i.e., moderators, covariates) that may potentially help account
for associations between dimensions of narcissism and stress responses. In the tables, whenever
studies examined additional variables, notes appear in italics in the corresponding cell of the ‘Findings’ column to summarise results.
Results
Associations between grandiosity and stress-reactivity
Psychological reactivity
Grandiosity appears to be broadly associated with altered psychological stress responses. Edelstein
et al. (2010) assessed grandiosity in men and women using the Narcissistic Personality Inventory
(NPI; Raskin & Hall, 1981) and examined changes in positive and negative affect in response to
social evaluative threat (i.e., using the Trier Social Stress Test; Kirschbaum, Pirke, & Hellhammer,
Table 1. Summary of articles examining associations between grandiosity and psychological stress responses.
Authors
Study design
Sample characteristics
Grandiosity measure
Stressor/Assessment of stress-reactivity
Findings
Atlas and Them
(2008)
Experimental
N = 106; 52.83% women,
undergraduate (age not
reported)
NPI
Affect: Grandiosity was associated with decreased negative
emotion following either positive or negative feedback, and
increased negative emotion following mixed feedback.
Association held after controlling for baseline internalised negative
emotion.
Besser and Priel
(2010)
Experimental
N = 448; 51% women;
Mage = 25.09, SD = 2.23,
range 20–30
EE
Besser and
Zeigler-Hill
(2010)
Experimental
N = 600; 50% women;
Mage = 24.07, SD = 2.25,
range = 20–30
PNI/G
Bond et al.
(2006)
Experimental
N = 60; 50% women; Mage
= 30.27, SD = 10.3
NPI
Drat-Ruszczak
et al. (2014)
Experimental
N = 104; 57% women;
Mage = 22.20, SD = 1.96
NPI
Social evaluative threat: Participants delivered a speech that was
videotaped and ‘evaluated’ by two judges. Participants then
received one of three types of feedback: (1) positive ratings from
both judges, (2) negative ratings from both judges, or (3) judges
gave mixed ratings. A negative emotion composite (‘angry at self’,
‘guilty’, ‘self-critical’, and ‘worthless’) was assessed before the
speech and after receiving feedback.
Achievement failure: One quarter of the participants read a highthreat achievement failure scenario (being passed over for a
desired promotion at work) and one quarter read a low-threat
scenario (the company secretary retires with no threat to the
participant’s job).
Rejection: One quarter of the participants read a high-threat
romantic rejection scenario (finding one’s partner having sexual
relations with another person) and one quarter read a low-threat
scenario (finding one’s partner alone in the house while
something sexually explicit plays on a television in an adjacent
room).
Anger and negative emotion (anxiety, dysphoria, and hostility)
were assessed before and after reading the scenarios.
Achievement failure: One quarter of the participants read a
‘private’ achievement failure scenario (being pulled aside by a
professor and told that one’s class presentation was horrible and
would receive a failing grade), and one quarter read a ‘public’
scenario (the professor announces to the entire class that the
presentation was horrible and would receive a failing grade).
Rejection: One quarter of the participants read a ‘private’
rejection scenario (being pulled aside at a party by a romantic
partner and told that he/she is having an affair and leaving the
relationship), and one quarter read a ‘public’ scenario (one’s
partner announces the infidelity and break-up in front of everyone
at the party).
A negative emotion composite (anxiety, dysphoria, hostility) was
assessed before and after reading the scenarios.
Negative interpersonal experiences: Participants listened to
pre-recorded scenarios that involved imagining a variety of
negative interpersonal experiences (i.e., being ignored by a taxi,
insulted at an office party, having a work presentation criticised,
and having one’s job made redundant). The presentation of
experiences was counterbalanced. Anger was assessed before and
after the scenarios.
Social evaluative threat: Participants were randomly assigned to
one of four feedback conditions in which they received letters of
recommendation they imagined coming from an important
mentor. The letters in the four conditions described their personal
characteristics along dimensions of agency (e.g., intelligence,
capability, effectiveness) and communion (e.g., friendliness,
selflessness, honesty), specifically: (1) positive agentic and
Affect: EE was associated with greater increases in anger and
negative emotion after imagined achievement failure, but not
rejection.
Type of threat scenario (achievement failure vs. rejection)
moderated associations between narcissistic traits and affective
reactions.
No interaction with gender.
Associations held after controlling for baseline composite negative
emotion and neuroticism.
Affect: Grandiosity was associated with increased negative
emotion after imagining achievement failure and rejection
occurring in public.
Type of threat scenario (public vs. private) moderated associations
between grandiosity and negative emotion.
Associations held after controlling for baseline negative emotion.
Self-perception: Grandiosity was associated with greater
increases in self-esteem when the agency dimension of feedback
was positive, and decreased self-esteem when the agency
dimension of feedback was negative. Grandiosity was not
associated with changes in self-esteem following feedback
regarding the communal dimension.
HEALTH PSYCHOLOGY REVIEW
Affect: Grandiosity was associated with increased anger in
response to imagined negative interpersonal experiences.
No interaction with gender.
No association after controlling for trait anger and baseline state
anger.
7
(Continued )
Authors
8
Table 1. Continued.
Study design
Sample characteristics
Grandiosity measure
Experimental
N = 90; 51% women;
Mage = 20.57, SD = 2.91
NPI
Geukes et al.
(2017)
Quasi-experimental
N = 299; 55% women;
Mage = 23.95, SD = 3.93
NPI
NARQ
Horton and
Sedikides
(2009)
Experimental
Kelsey et al.
(2001)
Nicholls and
Stukas (2011)
N = 120; sample
characteristics not
available
NPI
Quasi-experimental
N = 40 men; Mage = 25.00,
SD = 3.7, range = 21–32
NPI
Experimental
N = 40; 72.5% women,
Mage = 21.58 years,
SD = 6.40, range = 18–40
NPI
Findings
S. R. COLEMAN ET AL.
Edelstein et al.
(2010)
Stressor/Assessment of stress-reactivity
communal, (2) positive agentic and negative communal, (3)
negative agentic and positive communal, or (4) negative agentic
and communal. State self-esteem was assessed before and after
receiving feedback.
Social evaluative threat: Participants completed the Trier Social Affect: Grandiosity was associated with decreased positive affect
Stress Test (TSST; Kirschbaum et al., 1993). Positive and negative and increased negative affect following social evaluative threat.
affect were assessed before and after the TSST.
No interaction with baseline self-esteem.
Gender moderated association (only significant for men).
Associations held after controlling for self-esteem.
Interpersonal experiences: Participants attended three
Self-perception: NPI grandiosity was negatively associated with
laboratory sessions spaced one week apart and took part in a total self-esteem variability in response to interpersonal experiences.
of seven interpersonal interaction tasks. Session one involved
The admiration scale of the NARQ was negatively associated, and
reading aloud a neutral text, followed by one brief and one long the rivalry scale of the NARQ was positively associated with selfself-introduction, session two involved solving two group puzzles, esteem variability in response to interpersonal experiences.
and session three involved discussing a moral dilemma and
Compared to participants low in NARQ rivalry, participants high in
assigning adjectives (mildly or strongly positive or negative) to NARQ rivalry experienced greater decreases in self-esteem,
describe the other group members. State self-esteem was
particularly from the end of the second session to the beginning
assessed directly before and after each interaction task.
of the third session.
Association between NPI grandiosity and self-esteem variability
became nonsignificant after controlling for Big Five traits.
Associations between NARQ scales and self-esteem variability held
after controlling for Big Five traits.
Interpersonal perception: Participants higher in grandiosity
Social evaluative threat: Participants evaluated a videotaped
rated confederates less favourably after being negatively
interview of a confederate participant on favourability (i.e.,
composite intelligence, attractiveness, likeability, and co-worker evaluated.
potential) and were told that videotaped interviews they had
No interaction with gender.
previously produced were being similarly evaluated by the
Confederate status moderated association (only significant when
confederate. Participants were given either positive or negative participants believed the confederate was ‘single’).
evaluations. Furthermore, in the ‘low status’ condition participants
were told the confederate was ‘single’, and in the ‘high status’
condition the confederate was ‘recently married’. Participants’
evaluations of confederates were acquired before and after
learning how they had been evaluated.
Anticipatory threat: Participants completed one active and one Affect: Participants higher in grandiosity exhibited lower state
passive ‘countdown to aversive stimuli’ task, each with five trials of anxiety in response to anticipatory threat.
a visual countdown from 9 to 1 followed by a noise blast. In the
active task, participants could avoid the noise by pressing a
button. In the passive task, participants could not avoid the noise.
Ordering of task exposure was counterbalanced. State anxiety was
assessed at the beginning of the experiment and after each task.
Self-perception: Grandiosity was associated with greater
Social evaluative threat: Participants receiving threatening
feedback were told they had been outperformed by a friend (i.e., increases in comparative self-worth (i.e., moral principles and
th
th
competitiveness relative to the friend) in response to evaluative
scored in 30 percentile vs. the friend who scored in the 80
feedback (i.e., being outperformed by the friend).
percentile) on a bogus test of competitiveness. Participants
Interpersonal perception: Grandiosity was associated with
receiving non-threatening feedback were told that they had
th
scored in the 65 percentile and that their friend had scored in the greater reductions in relationship closeness after evaluative
feedback (i.e., being outperformed by the friend).
Peterson and
DeHart (2014)
Quasi-experimental
Rhodewalt and
Eddings (2002)
Experimental
N = 102 undergraduate
couples (100 heterosexual,
2 same sex); Mage = 20.73,
SD = 1.52
NPI
N = 67 men;
undergraduates (age not
reported)
NPI
NPI
Stressor type moderated association (only significant for
participants who had been outperformed).
Self-perception: Grandiosity was associated with greater
decreases in one’s own relationship commitment following
partner conflict.
No interaction with gender.
Association held after controlling for gender, baseline negative
affect, and pre-conflict own commitment.
Interpersonal perception: Grandiosity was associated with
increases in perceptions of partners’ relationship commitment
following partner conflict.
No interaction with gender.
Association held after controlling for gender, baseline negative
affect, and pre-conflict perceived partner commitment
Rejection: Participants were randomly assigned to be told they Affect: Grandiosity was not associated with changes in positive
had been either accepted or rejected by a potential dating partner emotion, but was associated with changes in negative emotion.
(i.e., a confederate). Positive and negative emotion, self-esteem, Experimental condition moderated association (compared to
personal dating histories, and how much participants liked the participants lower in grandiosity, participants higher in grandiosity
exhibited smaller increases in negative emotion).
confederate were assessed before and after acceptance or
Interpersonal perception: Grandiosity was not associated with
rejection.
changes in recalled favourability of potential dating partners
behaviours, likeability, or perceiving that they were liked by the
potential dating partner.
No interaction with experimental condition.
Memory and self-perception: Grandiosity was associated with
changes in personal dating histories and self-esteem.
Experimental condition moderated associations between
grandiosity and recalled personal dating histories (participants
higher in grandiosity distorted romantic histories to be more
positive after being rejected and more negative after being
accepted, and participants lower in grandiosity distorted their
romantic histories to be more positive after being accepted, and
more negative after being rejected).
Memory distortion moderated associations between grandiosity
and changes in self-esteem (participants higher in grandiosity who
distorted their romantic histories to be more positive did not
experience decreases in self-esteem following rejection, whereas
those higher in grandiosity who did not distort their romantic
histories exhibited decreases in self-esteem following rejection).
Social evaluative threat: Participants took two different but
Affect: In study 1, grandiosity was not associated with changes in
equivalent forms of a bogus intelligence test. For half of the
curiosity, but was associated with greater increases in anger and
participants, positive feedback on the second test followed
anxiety following evaluative feedback.
negative feedback on the first test, and for the other half of the Stressor type moderated associations (only significant for
participants the ordering of feedback was reversed. Test forms
participants receiving negative feedback on the second test).
were counterbalanced.
Moderated mediation with personal ability attributions (anger and
In study 1, participants completed measures of state anger,
anxiety reports were greatest for participants higher in grandiosity
anxiety, and curiosity before and after test 1, and after test 2. In who received positive feedback on test 1, attributed their success to
study 2, participants filled out measures of state anxiety,
personal ability, and then received negative feedback on test 2).
9
(Continued )
HEALTH PSYCHOLOGY REVIEW
Rhodewalt and Experimental Study N = 114; 50% women;
1
undergraduate (age not
Morf (1998)
Study reported)
2
N = 127; 52% women;
undergraduate (age not
reported)
60th percentile. Participants reported on the closeness of their
friendships before taking the test and after receiving their scores.
Interpersonal conflict: Participants engaged in a 7-minute
conflict interaction (i.e., recalled their last major argument and
tried to resolve it), followed by a positive interaction (i.e.,
discussed what they enjoy about each other and their relationship
for 3 min). Participants’ reported relationship commitment and
perceptions of their partners’ relationship commitment before the
conflict interaction and after the positive interaction.
Authors
10
Table 1. Continued.
Study design
Sample characteristics
Grandiosity measure
Stressor/Assessment of stress-reactivity
Sommer et al.
(2009)
Experimental
N = 74; 56.76% women,
undergraduates (age not
reported)
NPI
EE
MT
Thomaes et al.
(2010)
Experimental
N = 333; 51% girls; Mage =
10.8, SD = 0.9, range = 8–
12
CNS
Thomaes et al.
(2011)
Experimental
N = 175; 53% girls; Mage =
11.70, SD = 0.80, range =
10–13
CNS
Rejection: Participants listened to two rejection scenarios (one
involving rejection from friends and one involving infidelity and
rejection from a romantic partner) or two acceptance scenarios
(praise and acceptance from both friends and romantic partner).
Scenarios were presented in the same order for all participants.
Following each scenario, participants described how they would
feel and act in response to the situation. Felt rejection, anger, and
state self-esteem were assessed after each scenario.
Social evaluative threat: Participants were told they received
either the highest or lowest score in an online ‘popularity contest’
and received positive or negative feedback on their performance.
State self-esteem was assessed at baseline, after viewing the
results of the contest, and again after receiving performance
feedback.
Public shaming: Participants played an online game with a
fictitious opponent of the same age and gender from another
school. In the ‘shaming’ condition, participants were told they had
lost to ‘the worst player in the game’, and the web browser was
refreshed to show the participant’s name at the bottom of the
Findings
No interactions with gender.
Associations held after controlling for self-esteem, self-complexity,
and baseline anger and anxiety.
Affect: In study 2, grandiosity was associated with greater
increases in anger, smaller increases in anxiety and depression,
and smaller decreases in happiness in response to evaluative
feedback.
Stressor type moderated association (grandiosity was associated
with greater increases in anger following negative feedback, and
greater decreases in anger following positive feedback).
Moderated mediation with personal ability attributions (increases in
anger were greatest for participants higher in grandiosity who
received positive feedback on test 1, attributed their success to
personal ability, and then received negative feedback on test 2).
Associations held after controlling for self-esteem, self-complexity,
and baseline anger, anxiety, depression, and happiness.
Self-perception: Grandiosity was associated greater changes in
self-esteem following evaluative feedback.
No interaction between grandiosity and personal ability attributions
on changes in self-esteem.
Stressor type moderated association (grandiosity was associated
with increases in self-esteem following negative feedback).
Moderated mediation with personal ability attributions (increases in
self-esteem were greatest for participants higher in grandiosity who
received positive feedback on test 1, did not attribute success to
personal ability, and then received negative feedback on test 2).
Associations held after controlling for self-esteem, self-complexity,
and baseline anger, anxiety, depression, and happiness.
Affect: NPI grandiosity was associated with increased anger
following rejection from a romantic partner, and decreased anger
after being accepted by a romantic partner. Effects of EE and MT
grandiosity on anger were not reported. Effects of NPI, EE, and MT
on felt rejection were not reported.
Self-perception: Effects of NPI, MT, and EE on self-esteem were
not reported.
No interaction with gender reported.
Self-perception: Following negative feedback, children who
showed significant decreases in self-esteem scored higher in
grandiosity at baseline than children who did not show decreases
in self-esteem.
No interaction with age.
Affect: Grandiosity was associated with increased anger.
No interaction with gender.
Stressor type moderated association (children higher in grandiosity
exhibited greater increases in anger in response to shaming)
S. R. COLEMAN ET AL.
depression, anger, happiness, and self-esteem before and after
test 1, and after test 2.
Woodman et al.
(2011)
Quasi-experimental
N = 42; 50% women, Mage
= 23.31, SD = 1.16
NPI
Zeigler-Hill and
Besser (2013)
Daily Diary
cN = 372; 80.1% women;
Mage = 20.3, SD = 2.59
LA
GE
EE
PNI/G
scoreboard. In the ‘no shame’ condition, participants also lost but
received no information about their opponent’s ability and saw no
scoreboard rankings. Anger was assessed before and after the
game.
Social evaluative threat: Participants completed two cycle
ergometer tests in same-sex teams of three. Each participant was
isolated from the other team members and instructed to cycle as
far as possible for 10 min. In the ‘high identifiability’ test,
participants were told their individual performance would be
made public on University notice boards and the intranet. In the
‘low identifiability’ test, participants were told that only the team’s
overall performance would be publicised. Ordering of test
exposure was counterbalanced. Participants rated their perceived
exertion every three minutes.
Daily experiences: At the end of each day for seven days,
participants recorded positive and negative interpersonal events
and positive and negative achievement events via online survey.
State self-esteem was assessed at each survey.
Self-perception: Compared to participants low in grandiosity,
participants high in grandiosity reported greater increases in
perceived exertion during the ‘high identifiability’ test.
Self-perception: On days when more negative interpersonal
evens occurred, individuals scoring low in LA or GE exhibited
greater decreases in self-esteem than high scoring individuals.
Individuals scoring high in EE exhibited greater decreases in selfesteem than low scoring individuals. PNI grandiosity was
unrelated to daily changes in self-esteem.
HEALTH PSYCHOLOGY REVIEW
Note: NPI = Narcissistic Personality Inventory, LA = NPI Leadership/Authority subscale, GE = NPI Grandiose Exhibitionism subscale, EE = NPI Entitlement/Exploitativeness subscale, NARQ = Narcissistic Admiration and Rivalry
Questionnaire, PNI/G = Pathological Narcissism Inventory Grandiosity Scale, MT = Margolis-Thomas Measure of Narcissism, CNS = Childhood Narcissism Scale.
11
12
Table 2. Summary of articles examining associations between grandiosity and biological stress responses.
Study design
Ecological
Momentary
Assessment
Sample characteristics
N = 103; 46.6% girls;
grades 5 and 6
Stressor/Assessment of stress-reactivity
Daily interpersonal experiences: Participants were
assessed five times on each of four consecutive days
(Tuesday-Friday). Participants rated their
interpersonal experiences since the last assessment
on a scale from (1) negative – (7) positive. Salivary
cortisol was collected at each assessment.
Cascio et al. (2015)
Quasiexperimental
N = 39 men; Mage =
16.8, SD = 0.47, range
= 16–17
NPI
Social exclusion: Participants played Cyberball (a
virtual game of ball toss designed to simulate social
exclusion) while undergoing an fMRI scan.
Chester and DeWall
(2015)
Quasiexperimental
N = 20; 50% women;
Mage = 18.86, SD = 1.25
NPI
Social exclusion: Participants played Cyberball while
undergoing an fMRI scan.
Dane et al. (2018)
Quasiexperimental
N = 25 men; Mage =
23.16, SD = 6.31, range
= 18–43
NPI
Edelstein et al. (2010)
Experimental
N = 90; 51% women;
Mage = 20.57, SD = 2.91
NPI
Social evaluative threat: Participants played the
game ‘two truths and a lie’, in which they were asked
to think of three statements (two truthful and one
false) and told they would be videotaped and
evaluated on how well they lied. Cortisol was
assessed at baseline, immediately following the
game, and 20 min after the game, and testosterone
was assessed at baseline and 20 min after the game.
Social evaluative threat: Participants completed
the Trier Social Stress Test (TSST; Kirschbaum et al.,
1993). Salivary cortisol was collected before and after
the TSST.
Findings
Cortisol: Children high in grandiosity (i.e., selfrated as high in social competence but were rated
by peers as being ‘stuck up’ and generally disliked)
exhibited deficient cortisol responses to
interpersonal experiences.
Self-rated social competence, peer ratings, and
stressor type moderated associations (children who
self-rated as high in social competence who were
generally liked by peers exhibited increases in
cortisol following negative interpersonal experiences,
whereas children who self-rated as low in social
competence exhibited increases in cortisol following
positive interpersonal experiences regardless of peer
ratings).
Neural: Grandiosity was associated with increased
activity in the anterior insula (AI), dorsal anterior
cingulate cortex (dACC), and the AI, dACC,
subgenual ACC network during social exclusion.
Neural: Grandiosity was associated with dACC
activation during social exclusion.
‘Anxious attachment’ moderated association
(grandiosity was only associated with increased
activity in the dACC for individuals high in ‘anxious
attachment’).
Association held after controlling for rejection
sensitivity and threatened needs.
Cortisol: Grandiosity was not associated with
changes in cortisol in response to social evaluative
threat.
Testosterone: Participants high in grandiosity
exhibited an increase in testosterone following
social evaluative threat, whereas participants low
in grandiosity exhibited a decrease in testosterone
following social evaluative threat.
Cortisol: Grandiosity was associated with
heightened cortisol reactivity to social evaluative
threat.
No interaction with baseline self-esteem.
Gender moderated association (only significant for
men).
S. R. COLEMAN ET AL.
Grandiosity
measure
Observation/
nomination
Authors
Bukowski,
Schwartzman, Santo,
Bagwell, and Adams
(2009)
Quasiexperimental
N = 40 men; Mage =
25.00, SD = 3.7, range
= 21–32
NPI
Anticipatory threat: Participants completed one
active and one passive ‘countdown to aversive
stimuli’ task, each with five trials of a visual
countdown from 9 to 1 followed by a noise blast.
Active and passive tasks are described in Table 1. SC,
HP, and PEP were monitored continuously.
Sommer et al. (2009)
Experimental
N = 74; 56.76% women,
undergraduates (age
not reported)
NPI
EE
MT
Rejection: Participants listened to two rejection
scenarios (one involving rejection from friends and
one involving infidelity and rejection from a romantic
partner) or two acceptance scenarios (praise and
acceptance from both friends and romantic partner).
Scenarios were presented in the same order for all
participants. Following each scenario, participants
described how they would feel and act in response to
the situation. BP and HR were assessed continuously.
Sylvers et al. (2008)
Quasiexperimental
N = 100; 51% women;
age range = 18–21
SCID-II
Anticipatory threat: Participants completed a
passive ‘countdown to aversive stimuli’ task with five
trials of a visual count from 1 to 12 followed by a
noise blast.
Emotion induction: Participants were presented
emotionally valenced slides from the International
Affective Picture System (IAPS; Lang, Bradley, &
Cuthbert, 1999). Slides were presented in sets of 10
over four trials: (1) positive, (2) fear, (3) sad, and (4)
neutral.
RSA, PEP, and SC were monitored continuously
13
(Continued )
HEALTH PSYCHOLOGY REVIEW
Kelsey et al. (2001)
Association held after controlling for baseline selfesteem.
SC: Grandiosity was associated with faster SC
habituation to anticipatory threat regardless of
coping resources.
HP: Grandiosity was associated with increased HP
lengthening in response to anticipatory threat
regardless of coping resources.
PEP: Grandiosity was associated with increased
PEP shortening in response to anticipatory threat.
Timing of trials moderated association (participants
higher in grandiosity showed the greatest PEP
shortening during the 1st task and slower
attenuation of PEP over trials regardless of coping
resources).
BP: NPI grandiosity was not associated with BP. MT
grandiosity was associated with greater increases
in SBP and DBP in response to rejection. EE was
associated with greater increases in SBP in
response to rejection.
HR: NPI grandiosity was marginally associated with
lower HR during rejection, and MT grandiosity was
associated with elevated HR during minutes 2 and
4 of the recovery period.
No interaction with gender.
Associations held after controlling for baseline BP
and HR.
RSA: Grandiosity (i.e., features of Narcissistic
Personality Disorder) was associated with RSA
decreases while viewing happy slides, but was
unrelated to changes in RSA while viewing fear or
sad slides. RSA for anticipatory threat was not
reported.
Associations held after controlling for features of
antisocial, borderline, and histrionic personality
disorders.
No interaction with gender.
PEP: Grandiosity (i.e., features of Narcissistic
Personality Disorder) was not associated with PEP
during anticipatory threat, but was associated with
PEP shortening while viewing happy or sad slides.
Association became nonsignificant after controlling
14
Authors
Study design
Sample characteristics
Grandiosity
measure
Woodman et al. (2011)
Quasiexperimental
N = 42; 50% women,
Mage = 23.31, SD = 1.16
NPI
Zhang, Wang, You, Lü,
and Luo (2015)
Quasiexperimental
N = 227; 82.8% women,
Mage = 19.9, SD = 1.01,
range 17–23
NPI
Stressor/Assessment of stress-reactivity
Social evaluative threat: Participants completed
two cycle ergometer tests in same-sex teams of
three. Each participant was isolated from the other
team members and instructed to cycle as far as
possible for 10 min. In the ‘high identifiability’ test,
participants were told their individual performance
would be made public on University notice boards
and the intranet. In the ‘low identifiability’ test,
participants were told that only the team’s overall
performance would be publicised. Ordering of test
exposure was counterbalanced. HR was monitored
continuously.
Social evaluative threat: Participants were
videotaped performing a mock job interview and
told the tapes would be evaluated by experts. HR
and RSA were monitored continuously.
Findings
for features of antisocial and histrionic personality
disorders.
No interaction with gender.
SC: Grandiosity (i.e., features of Narcissistic
Personality Disorder) was not associated with SC
during anticipatory threat or emotion induction.
No interaction with gender.
HR: Grandiosity was associated with increased HR
during the ‘high identifiability’ cycling test.
No interaction with gender.
HR: Grandiosity was not associated with changes
in HR during the interview.
Based on zero-order correlations.
RSA: Grandiosity was not associated with changes
in RSA during the interview.
Based on zero-order correlations.
Note: NPI = Narcissistic Personality Inventory, EE = NPI Entitlement/Exploitativeness subscale, MT = Margolis-Thomas Measure of Narcissism, SCID-II = Structured Clinical Interview for DSM-IV Axis II
Personality Disorders. Abbreviations for indicators of biological reactivity: SC = Skin Conductance, HP = Heart Period, PEP = Pre = Ejection Period, BP = Blood Pressure, SBP = Systolic Blood Pressure,
DBP = Diastolic Blood Pressure, HR = Heart Rate, RSA = Respiratory Sinus Arrhythmia.
S. R. COLEMAN ET AL.
Table 2. Continued.
HEALTH PSYCHOLOGY REVIEW
15
1993; Table 1). Grandiosity was associated with greater decreases in positive affect and increases in
negative affect following social evaluative threat, but only for men. In another study, NPI grandiosity
was associated with greater increases in negative affect after receiving mixed feedback from judges
following a public speaking task (i.e., one positive and one negative evaluation), and greater
decreases in negative affect after receiving entirely positive or negative feedback (Atlas & Them,
2008; Table 1). In a study of undergraduate men who were led to believe they had been rejected
by a potential female dating partner, NPI grandiosity was not associated with changes in positive
emotions, but compared to men low in grandiosity, men high in grandiosity exhibited smaller
increases in negative emotion (Rhodewalt & Eddings, 2002; Table 1). In a 2-part study by Rhodewalt
and Morf (1998), participants were given two different but equivalent forms of a bogus ‘intelligence
test’ after completing the NPI (Table 1). Half of the participants received negative feedback on the first
form and positive feedback on the second form, and half received positive feedback on the first form
and negative feedback on the second form. In study 1, grandiosity was associated with increased
anger and anxiety when participants received negative feedback on the second form. In contrast,
study 2 demonstrated that relative to participants low in grandiosity, participants high in grandiosity
exhibited smaller increases in anxiety and depression, and smaller decreases in happiness regardless
of feedback quality. However, high grandiosity was also associated with greater anger increases when
negative feedback followed positive feedback, and greater anger decreases when positive feedback
followed negative feedback. Additionally, increases in anger were greatest for participants high in
grandiosity who attributed their success on the first form of the intelligence test to personal
ability. One other study found no association between NPI grandiosity and changes in anxious
affect in response to anticipatory threat modelled with a countdown to an aversive noise task
(Kelsey et al., 2001; Tab1e 1).
Grandiosity has also been associated with affective reactivity to evaluative stressors in children.
Thomaes, Stegge, Olthof, Bushman, and Nezlek (2011) administered the Childhood Narcissism Scale
(CNS; Thomaes, Stegge, Bushman, Olthof, & Denissen 2008) to pre-adolescents who then played a
bogus online game with an opponent of the same gender from another school (Table 1). Children
were randomly assigned to either a neutral condition (i.e., losing the game) or a ‘shaming’ condition
(i.e., losing to ‘the worst player in the game’ and seeing their name replace the worst player’s name
on a ‘very popular’ fictitious webpage). CNS grandiosity was associated with heightened anger for children in the shaming condition. Together with the evidence presented above, these results suggest that
grandiosity has been broadly associated with stress-related changes in affect, but may have a greater
effect on affective responses when stressors explicitly threaten personal attributes.
Studies have also demonstrated associations between grandiosity and affective responses to imagined stressors. In one study, participants completed the NPI before being presented with prerecorded scenarios that involved imagining a series of potentially stressful interpersonal events
(i.e., being ignored by a taxi, insulted at an office party, having a work presentation heavily criticised,
and finally having one’s job made redundant; Bond, Ruaro, & Wingrove, 2006; Table 1). NPI grandiosity was associated with increased anger after listening to the scenarios, but the association became
non-significant after controlling for trait anger, which might suggest that individuals higher in grandiosity are generally prone to anger. In another study, participants completed the NPI before reading
either (A) an achievement failure scenario that involved being passed over for a desired promotion at
work, or (B) a romantic rejection scenario that involved witnessing infidelity then being rejected by
one’s partner (Besser & Priel, 2010; Table 1). The ‘Entitlement/Exploitativeness’ facet (i.e., a trait associated with grandiosity characterised by a willingness to manipulate others to meet entitled expectations for recognition and admiration) was associated with increased negative affect following
imagined achievement failure, but not rejection. In another study, Besser and Zeigler-Hill (2010)
demonstrated that grandiosity assessed with the PNI grandiosity scale was associated with increased
negative emotion after imagining public achievement failure and rejection, but not private achievement failure or rejection, and these associations held after controlling for common variance shared
with the PNI vulnerability scale. In one other study, NPI grandiosity was associated with increases in
16
S. R. COLEMAN ET AL.
anger following imagined rejection, and decreases in anger following imagined acceptance (Sommer
et al., 2009; Table 1). Overall, these results suggest that imagining interpersonal stress may elicit
heightened affective reactivity for individuals higher in grandiosity, but also suggest that trait
anger may be an important aspect of personality to control for in future studies.
Grandiosity has also been associated with stress-related changes in self-perception (including selfconcept and perceived somatic activity) and memory distortion. In a study by Rhodewalt and Morf
(1998), compared to participants low in NPI grandiosity, participants high in NPI grandiosity exhibited
greater decreases in self-esteem when negative feedback followed positive feedback, and greater
increases in self-esteem when positive feedback followed negative feedback (Table 1). In another
study, participants completed the NPI and were randomly assigned to one of four feedback conditions in which they received letters of recommendation they imagined came from an admired
mentor (Drat-Ruszczak, Bazińska, & Niemyjska, 2014; Table 1). In the first condition, participants
were described as intelligent, capable, and effective (i.e., positive agentic) and friendly, selfless,
and honest (i.e., positive communal). In the second condition, participants were described as positive
agentic and negative communal (i.e., unfriendly, selfish, dishonest). In the third, participants were
described as negative agentic (i.e., unintelligent, incapable, and ineffective) and positive communal,
and in the fourth condition participants were described as negative agentic and negative communal.
Grandiosity was associated with greater increases in self-esteem when agency feedback was positive,
greater decreases in self-esteem when agency feedback was negative, and was not associated with
changes in self-esteem in response to communion feedback. Similarly, NPI grandiosity has been
associated with increases in comparative self-worth (i.e., ratings of one’s own self-worth with
respect to moral principles and competitiveness relative to a close friend) in response to being outperformed by a close friend on a bogus test of competitiveness (Nicholls & Stukas, 2011).
Research has also demonstrated that relative to men low in grandiosity, men high in grandiosity
may distort their personal dating histories to be more positive following rejection by a potential
dating partner, and more negative following acceptance by a potential dating partner (Rhodewalt
& Eddings, 2002). Interestingly, men low in grandiosity exhibited the opposite pattern of memory distortion, and memory distortion interacted with grandiosity such that men high in grandiosity who
distorted their dating histories to be more positive did not report decreases in self-esteem following
rejection, whereas men high in grandiosity who did not distort their personal dating histories exhibited decreases in self-esteem following rejection (Table 1). In a quasi-experimental study, participants
completed the NPI followed by two team cycle ergometer tests (counter-balanced across participants; Woodman, Roberts, Hardy, Callow, & Rogers, 2011; Table 1). One test involved a ‘low identifiability’ condition in which participants were told that their individual performance would be kept
anonymous, and the other test involved a ‘high identifiability’ condition in which participants were
told that their individual performance would be made public. Compared to participants low in grandiosity, those high in grandiosity reported greater physical exertion in the high identifiability condition.
In a different quasi-experimental study, participants completed the NPI and the Narcissistic Admiration and Rivalry Questionnaire (NARQ; Back et al., 2013) and were randomly assigned to groups of 4–6
individuals (Geukes et al., 2017; Table 1). In response to potentially stressful group interactions (e.g.,
assigning mildly or strongly positive or negative adjectives to other group members), NPI grandiosity
and the admiration scale of the NARQ were negatively associated with self-esteem variability, and the
rivalry scale of the NARQ was positively associated with self-esteem variability. Compared to participants low in NARQ rivalry, participants high in NARQ rivalry experienced greater decreases in selfesteem. Importantly, associations between NARQ scales and self-esteem variability held after controlling for Big Five traits, but the negative association between the NPI and self-esteem variability
became nonsignificant after controlling for Big Five traits. Since the NPI was positively correlated
with extraversion and negatively correlated with neuroticism in this study, these findings may
suggest that a general proclivity for socialising (i.e., extraversion) coupled with lower emotional
instability (i.e., neuroticism) may help explain why individuals higher in NPI grandiosity were resistant
to self-esteem variability following stressful interpersonal experiences. Moreover, these results may
HEALTH PSYCHOLOGY REVIEW
17
suggest that antagonistic qualities associated with narcissism (e.g., rivalry) may have the potential to
drive associations between grandiosity and stress-related changes in self-esteem.
In a daily diary study, individuals scoring high on the NPI facet subscales ‘Leadership/Authority’
(i.e., a trait characterised by a preoccupation with social status and associated recognition) or ‘Grandiose Exhibitionism’ (i.e., a trait characterised by a tendency to show off and to like being the centre of
attention) did not exhibit decreases in self-esteem on days when more negative interpersonal events
occurred, whereas individuals scoring low on either subscale did exhibit decreases in self-esteem
(Zeigler-Hill & Besser, 2013). On the other hand, individuals scoring high on the ‘Entitlement/Exploitativeness’ subscale (i.e., also associated with grandiosity, as previously noted) exhibited greater
decreases in self-esteem compared to low scoring individuals (Table 1). Finally, among children,
grandiosity has been associated with decreases in self-esteem after coming in last place in a
bogus online ‘popularity contest’ (Thomaes et al., 2010; Table 1). Overall, these results suggest grandiosity may influence stress-related changes in both self-perception and memory. However, individuals
high in grandiosity may have additional characteristics that potentially buffer stress responses (e.g., a
general tendency to enjoy being around people regardless of the quality and/or valence of social
interactions, emotional stability, or a tendency to engage in self-deceptive self-enhancement), or
enhance (e.g., antagonism, disagreeableness) depending on the type of stressor (e.g., interpersonal
rejection, competition, social evaluative threat).
Lastly, grandiosity has been associated with stress-related changes in perceptions of others and
perceptions of one’s relationships with others. For example, one study demonstrated that after
being insulted by confederates of the opposite sex/gender, NPI grandiosity was associated with
greater decreases in perceptions of confederates’ physical attractiveness and co-worker potential
(Horton & Sedikides, 2009; Table 1). However, perceived social status of interaction partners moderated the association between grandiosity and stress-related changes in perceptions of confederates,
such that the association only emerged when participants believed the confederates were ‘single’ as
opposed to ‘recently married’. On the other hand, one experimental study demonstrated that among
men rejected by potential dating partners, NPI grandiosity was unrelated to changes in ratings of the
potential dating partners’ likeability (Rhodewalt & Eddings, 2002; Table 1). In an observational study,
participants and their romantic partners engaged in a conflict interaction (i.e., participants were
instructed to try and resolve their last major disagreement; Peterson & DeHart, 2014), and NPI grandiosity was associated with decreases in personal relationship commitment and increases in perceptions of partners’ relationship commitment (Table 1). NPI grandiosity has also been associated with
decreases in perceived closeness with a friend after being told that the friend would compete to a
higher degree and with more success in life based on the results of a bogus test of competitiveness
(Nicholls & Stukas, 2011; Table 1). Taken together, these results suggest grandiosity may be associated
with stress-related changes in perceptions of others and of one’s relationships, which in turn has
implications for social functioning and associated health outcomes (e.g., impaired social functioning
is a known risk factor for mortality; House, Landis, & Umberson, 1988).
In summary, these studies constitute preliminary evidence that grandiosity has broadly associated
with altered psychological stress responses. In particular, we see relatively consistent evidence that
grandiosity has been associated with stress-related increases in negative affect (Atlas & Them,
2008; Besser & Priel, 2010; Besser & Zeigler-Hill, 2010; Edelstein et al., 2010), and several studies
found grandiosity to predict greater stress-related increases in specific negative affective states
such as anger (Besser & Priel, 2010; Bond et al., 2006; Rhodewalt & Morf, 1998; Sommer et al.,
2009; Thomaes et al., 2011). Several studies also demonstrated grandiosity to predict stress-related
changes in self-perception, including greater self-esteem variability (Drat-Ruszczak et al., 2014; Rhodewalt & Morf, 1998; Rhodewalt & Eddings, 2002; Thomaes et al., 2010; Zeigler-Hill & Besser, 2013) and
increases in perceived somatic activity (Woodman et al., 2011), and studies have found grandiosity to
predict stress-related changes in perceptions of others (Horton & Sedikides, 2009) as well as perceptions of one’s relationships (Nicholls & Stukas, 2011; Peterson & DeHart, 2014). Importantly, careful
review of these studies suggests that associations between grandiosity and psychological stress-
18
S. R. COLEMAN ET AL.
reactivity may hold after controlling for conceptually related aspects of personality, such trait selfesteem and self-complexity (i.e., the number of independent dimensions into which self-knowledge
is organised, including roles such as ‘student’, ‘friend,’ or ‘co-worker’). Furthermore, stressors involving
social evaluative components appear to be especially threatening to individuals high in grandiosity,
particularly when personal agency is threatened. Additional moderators, including sex, perceived
differences in social status, and/or cognitive processes involved in self-deceptive self-enhancement
may influence associations between grandiosity and psychological stress responses, and trait
anger may constitute an important covariate to help explain associations between grandiosity and
psychological stress responses.
Biological reactivity
In addition to psychological stress-reactivity, grandiosity has also been associated with altered biological stress-reactivity. Two fMRI studies administered the NPI at baseline, then used Cyberball (a
computer game of ball toss designed elicit a sense of social inclusion or exclusion; Williams &
Jarvis, 2006) to examine whether grandiosity associated with heightened neural activation in
response to social exclusion (Table 2). In the first study, grandiosity was associated with heightened
local activation in the anterior insula (AI) and dorsal anterior cingulate cortex (dACC), and general activation in the AI, dACC, subgenual ACC network during social exclusion (Cascio, Konrath, & Falk, 2015).
In the second study, grandiosity was associated with increased dACC activation during social exclusion (Chester & DeWall, 2015), but only for individuals concurrently higher on ‘anxious attachment’
(an attachment pattern characterised by hypersensitivity to social threats and a tendency to avoid
situations that may lead to rejection; Fraley & Waller, 1998). The finding from the second study
might suggest that grandiosity has the potential to exacerbate stress responses for individuals
who report/exhibit sensitivities to specific stressors such as social exclusion.
In addition to the two studies examining neural responses, three studies examined associations
between grandiosity and endocrine reactivity. In an ecological momentary assessment study, preadolescent children high in grandiosity (i.e., children who self-rated as having high social competence
but were nominated by their peers as being more ‘stuck up’ and generally self-absorbed compared to
their other classmates) exhibited no difference in cortisol responses to positive or negative interpersonal experiences in daily life (Bukowski et al., 2009). In contrast, children whose self-rated social competence was high and commensurate with peer evaluations exhibited an anticipated rise in cortisol
following negative interpersonal experiences, and children who self-rated as low in social competence exhibited a rise in cortisol following positive interpersonal experiences regardless of peer nominations (Table 2). This finding suggests that children who exhibit self-distortions consistent with
grandiosity may be unable to mount an adaptive cortisol response. In an experimental study utilising
a sample of adult men and women, NPI grandiosity was associated with heightened cortisol reactivity
to the Trier Social Stress Test (Kirschbaum et al., 1993), but only among men (Edelstein et al., 2010;
Table 2). On the other hand, in a quasi-experimental study involving a sample of only men, NPI
grandiosity was not associated cortisol responses to a social evaluative task that involved being evaluated on one’s ability to lie convincingly; however, men high in grandiosity exhibited increases in
testosterone in response to the task, and men low in grandiosity exhibited decreases in testosterone
(Dane et al., 2018; Table 2). Taken together, these studies suggest grandiosity may contribute to
heightened neuroendocrine reactivity in response to psychosocial stress, but age and sex of participants may influence associations between grandiosity and neuroendocrine stress responses, and
attachment anxiety may be an important individual difference to account for in future research.
Three studies examined whether narcissism associated with cardiovascular stress-reactivity. One
study assessed grandiosity using the NPI and the Margolis-Thomas Measure of Narcissism (MT; Margolis & Thomas, 1980) and examined how each measure associated with cardiovascular responses to
imagined rejection (Sommer et al., 2009). NPI grandiosity was marginally associated (i.e., p < .06) with
decreased heart rate, but not blood pressure. On the other hand, the ‘Entitlement/Exploitativeness’
facet was associated with greater systolic blood pressure. MT grandiosity was associated with
HEALTH PSYCHOLOGY REVIEW
19
increased heart rate during the recovery period as well as greater systolic and diastolic blood pressure
during imagined rejection (Table 2). In the cycle ergometer study described in the previous section of
psychological stress-reactivity (i.e., Woodman et al., 2011), NPI grandiosity was associated with
increased heart rate in the ‘high identifiability’ condition in which participants were told that their
performance would be made public (Table 2). On the other hand, one study found no association
between NPI grandiosity and changes in heart rate during a mock job interview; however, this
finding was based on zero-order correlations, which do not control for subject heterogeneity
(Zhang et al., 2015; Table 2). Together, these studies indicate that grandiosity has been associated
with cardiovascular stress responses, but the various measures of grandiosity may differentially
associate with cardiovascular reactivity, which suggests variants of grandiosity may differentially
associate with stress responses. Furthermore, it is likely important to control for subject heterogeneity
when examining associations between grandiosity (and vulnerability) and stress-reactivity (i.e., controlling for baseline states in regression models predicting difference scores).
Finally, three studies examined associations between grandiosity and general autonomic nervous
system (ANS) reactivity (e.g., cardiovascular and skin conductance responses simultaneously). Kelsey
et al. (2001) and Sylvers et al. (2008) administered the NPI then exposed participants to the countdown-to-an-aversive-stimulus (noise blast) task to model anticipatory threat. Heart period (HP),
pre-ejection period (PEP), and skin conductance (SC) were monitored continuously. Kelsey et al.
(2001) observed associations between NPI grandiosity and HP lengthening (i.e., enhanced cardiac
deceleration), increased PEP shortening, slower PEP habituation, and faster SC habituation over
five trials of the countdown task, and these associations held despite the availability of an active
coping resource (i.e., a button that could be pressed to cancel the noise) (Table 2). In contrast,
Sylvers et al. (2008) assessed grandiosity with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) and observed no associations between SCID-II grandiosity and ANS responses to anticipatory threat. On the other hand,
SCID-II grandiosity was associated with increased PEP shortening in response to emotion induction
(specifically, viewing happy or sad slides from the International Affective Picture System; Lang
et al., 1999), as well as decreases in respiratory sinus arrhythmia (RSA) while viewing happy slides,
but not frightening or sad slides (Table 2). However, associations between SCID-II grandiosity and
ANS responses to emotion induction became nonsignificant after controlling for features of borderline, antisocial, and histrionic personality disorders, which might suggest individuals higher in pathological grandiosity exhibit heightened ANS responses to emotion induction due to shared features of
dramatic or overly emotional thinking. Lastly, one study found no association between NPI grandiosity and RSA reactivity to mock job interviews based on zero-order correlations (Zhang et al., 2015;
Table 2).
In summary, we see evidence that grandiosity has been associated with altered biological stress
responses, as well as preliminary evidence that grandiosity may be associated with an inconsistent or
dysregulated biological stress response (e.g., heightened activation in stress-related brain regions
and subsequent exaggeration or blunting of ANS responses). However, the inconsistent findings in
this relatively small body of literature suggest that associations between grandiosity and biological
responses may depend on the particular measure utilised and, consequently, the variant of grandiosity measured (i.e., ‘normal’ vs. ‘pathological’), the type of stressor (e.g., social evaluative threat,
social exclusion/rejection, anticipatory threat, emotion induction), and/or the biological response
under investigation (e.g., neural, endocrine, cardiovascular, etc.).
Behavioural reactivity
Five studies examined associations between grandiosity and stress-related aggression (aggressive
tendencies have long been associated with poor health outcomes, such as cardiovascular disease;
Jenkins, Rosenman, & Zyzanski, 1974). One study used an economic simulation (i.e., FISH 3.1, in
which profits can be maximised by working cooperatively with others to catch fish against the associated costs of fishing; Gifford & Gifford, 2000) to examine whether NPI grandiosity influenced
20
S. R. COLEMAN ET AL.
aggressive behaviours (i.e., cutting an opponent’s fishing lines or fining them $100 to sabotage their
performance) following negative performance feedback on an earlier trial of the simulation (Barry,
Chaplin, & Grafeman, 2006; Table 3). Participants higher in NPI grandiosity who received negative
feedback aggressed against their opponents more frequently during a second trial, and the association between NPI grandiosity and aggression was strongest among men and when the negative performance feedback was normative (i.e., relative to others) rather than ipsative (i.e., relative to a one’s
own performance during a practice trial) or idealised (i.e., relative to a pre-set standard). In an observational study, conflict interactions between romantic partners were videotaped and coded for
aggressive behaviours such as using criticism, insults, name-calling, yelling, or responding sarcastically (Peterson & DeHart, 2014). NPI grandiosity was associated with more frequent aggressive behaviour during conflict interactions (Table 3). In a 7-day ecological momentary assessment study,
grandiosity was assessed with the grandiosity scale of the Pathological Narcissism Inventory (PNI;
Pincus et al., 2009), and participants completed up to eight paper diaries per day following each
in-person interaction lasting more than 5 min (Roche, Pincus, Conroy, Hyde, & Ram, 2013). For
each interaction, participants recorded perceptions of their interaction partners’ relative levels of
agency (e.g., dominance, status) and communion (e.g., warmth, friendliness), as well as their own
agentic and communal behaviours. Aggressive responses were defined as increased agentic behaviour in response to ‘status threats’ (i.e., perceiving high agency in an interaction partner) and
increased agentic or decreased communal behaviour in response to ‘rejection threats’ (i.e., perceiving
high agency and/or low communion in an interaction partner). Grandiosity was associated with
heightened aggression during daily social interactions; however, this association was qualified by
a significant four-way interaction with PNI vulnerability, perceptions of an interaction partner’s
agency, and perceptions of an interaction partner’s communion (Table 3). This four-way interaction
is detailed further below in the section on associations between vulnerability and behavioural reactivity. In another ecological momentary assessment study, features of Narcissistic Personality Disorder
(NPD) were assessed with the Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl, Blum, &
Zimmerman, 1997). For 21 days, participants completed electronic records following every social
interaction that lasted more than 10 min (Table 3). For each record, participants reported interpersonal dominant and submissive behaviour of self and other, interpersonal quarrelsome and agreeable
behaviour of self and other, and momentary negative affect. Grandiosity (i.e., features of NPD) was
associated with heightened quarrelsome behaviour in response to perceived dominance in social
interaction partners. Interestingly, increases in negative affect mediated the association between perceived dominance and quarrelsome behaviour responses, and grandiosity amplified the withinperson associations between perceived dominance, negative affect, and quarrelsome behaviours.
Grandiosity has also been associated with stress-related aggression in children. A daily diary study
of pre-adolescent boys and girls demonstrated that compared to girls and boys low on grandiosity,
boys high on grandiosity were rated by their classmates as becoming more ‘angry or furious’ on days
when stressful events occurred (Thomaes et al., 2011; Table 3). Together with the evidence presented
above, our examination of these studies indicates that grandiosity has been generally associated with
stress-related increases in aggression. Furthermore, these associations may hold after controlling for
additional features of personality disorders (e.g., Antisocial Personality Disorder), as well as positive
behaviours that may arise in response to interpersonal stress (e.g., expressing understanding, agreement, or concern, or rephrasing an interaction partner’s words; Peterson & DeHart, 2014). However,
some of the evidence presented suggests sex/gender could moderate associations between grandiosity and stress-related aggression. More importantly, associations between grandiosity (and vulnerability) and aggression have been previously reported (Rasmussen, 2016), and the current review
aligns with these reports.
One final study suggests grandiosity may influence stress-related changes in physical activity.
Woodman et al. (2011) examined the association between NPI grandiosity and distance cycled in
response to social evaluative threat. As described in previous sections, participants completed a
‘high identifiability’ (i.e., public) test and a ‘low identifiability’ (i.e., anonymous) test. Relative to
Table 3. Summary of articles examining associations between grandiosity and behavioural stress responses.
Grandiosity
measure
NPI
Study design
Experimental
Sample characteristics
N = 120; 50% women,
Mage = 21.58 years,
SD = 6.40, range = 18–40
Peterson and
DeHart
(2014)
Quasiexperimental
N = 102 undergraduate
couples (100 heterosexual,
2 same sex); Mage = 20.73,
SD = 1.52
NPI
Roche et al.
(2013)
Ecological
Momentary
Assessment
N = 184; 66% women,
Mage = 19.3, SD = 2.8,
range = 18–54
PNI/G
Stressor/Assessment of stress-reactivity
Social evaluative threat: Participants played 3 trials of
FISH 3.1 (Gifford & Gifford, 2000), a game to maximise
fishing profits against costs. The game was presented
as being linked to intelligence. Aggression was defined
as cutting an opponents’ fishing lines or fining an
opponent $100 during the game. After the 2nd trial,
players were given written feedback about their
performance from the simulated player. Feedback was
framed as ipsative (i.e., 2nd trial compared to 1st trial),
idealised (i.e., 2nd trial compared to goal previously set
by participant), or normative (i.e., 2nd trial compared to
other students who played the game). Aggressive
behaviours during the 3rd trial were compared to
aggressive behaviours during the 2nd trial to assess
changes in aggression following evaluative feedback.
Interpersonal conflict: Romantic partners engaged in
a 7-minute conflict interaction (described in Table 1)
followed by a positive interaction (also described in
Table 1). Discussions were videotaped and coded for
aggressive behaviours (i.e., criticism, complaining
about partner’s personality or character, using insults
or name calling, snapping or yelling, and responding
sarcastically). Positive behaviours were also coded (i.e.,
expressing understanding, agreement, caring, or
concern, rephrasing partners’ words, and reassuring
love).
Daily interpersonal experiences: For seven days,
participants completed paper diaries for each face-toface interaction lasting more than five minutes (up to
eight diaries per day). For each diary, participants
reported their perceptions of interaction partners’
agency (e.g., dominance) and communion (e.g.,
friendliness), as well as their own agentic and
communal behaviour. Aggressive behaviours were
defined as high agentic responses to perceived ‘status
threats’ (i.e., perceiving high agency in another) or high
agentic or low communal responses to ‘rejection
Findings
Aggression: Grandiosity was associated with
increased aggression following negative feedback.
Gender moderated association (association between
grandiosity and aggressive reactivity was strongest in
men).
Stressor type moderated association (association
between grandiosity and aggressive reactivity was
strongest when negative feedback was normative
rather than ipsative or idealised).
Aggression: Grandiosity was associated with more
aggressive behaviour during conflict interactions, but
was not associated with changes in positive
behaviours.
No interaction with gender.
Association held after controlling for gender, positive
behaviours, and baseline negative affect.
Aggression: Grandiosity was associated with
aggressive responses to daily interpersonal
experiences.
Partner characteristics and vulnerability moderated
associations (participants who were high in PNI
grandiosity and low in PNI vulnerability who perceived
simultaneously high agency and communion in an
interaction partner reported greater increases in
agency; participants who were simultaneously high in
PNI grandiosity and PNI vulnerability who perceived
high agency and communion in an interaction partner
reported greater increases in agency; participants
21
(Continued )
HEALTH PSYCHOLOGY REVIEW
Authors
Barry et al.
(2006)
22
Authors
Study design
Sample characteristics
Grandiosity
measure
Thomaes et al.
(2011)
Daily Diary
N = 383; 52% girls; Mage =
11.20, SD = 0.70, range =
10–13
CNS
Woodman
et al. (2011)
Quasiexperimental
N = 42; 50% women,
Mage = 23.31, SD = 1.16
NPI
Wright et al.
(2017)
Ecological
Momentary
Assessment
N = 102, 76.5% women,
Mage = 29.74, SD = 5.87
SIDP-IV
Stressor/Assessment of stress-reactivity
threats’ (i.e., perceiving high agency and/or low
communion in another).
Daily stressors: For 10 days, before going home at the
end of each school day, participants completed an
event checklist to indicate the stressful experiences
they had encountered during school hours (i.e.,
personal failure, awkward/unusual behaviour,
disappointment from others, disregard from others,
ridicule from others, or having a secret revealed). They
also nominated students who ‘got angry or furious’
that day.
Social evaluative threat: Participants completed two
10-minute cycle ergometer tests: one ‘high
identifiability’ and one ‘low identifiability’ test
(described in Table 1). Distance cycled was recorded
during both tests.
Daily interpersonal experiences: Participants
submitted electronic records via smartphone every day
for 21 days. Records were submitted following every
interpersonal interaction that lasted at least 10 min.
Each record assessed momentary interpersonal
dominance (e.g., I expressed an opinion; I asked the
other to do something) and submissive behaviour (e.g.,
I gave in; I let the other make plans or decisions) of self
and other, interpersonal quarrelsome (e.g., I criticised
the other; I made a sarcastic comment) and agreeable
behaviour (e.g., I listened attentively to the other; I
expressed reassurance) of self and other, and
momentary negative affect.
Findings
simultaneously high in PNI grandiosity and PNI
vulnerability who perceived high agency and low
communion in an interaction partner reported greater
decreases in agency).
Aggression: Children higher in grandiosity were
viewed by their peers as becoming more ‘angry or
furious’ on days when stressful events occurred.
Gender moderated association (compared to girls and
boys low in grandiosity, boys high in grandiosity were
perceived as expressing more anger on days when they
experienced a stressor).
Physical activity: Grandiosity was associated with
greater cycling distance during the ‘high
identifiability’ test.
No interaction with gender.
Aggression: Grandiosity (i.e., features of Narcissistic
Personality Disorder) was associated with heightened
quarrelsome behaviour in response to perceived
dominance in social interaction partners.
Increases in negative affect mediated the association
between perceived dominance in social interaction
partners and quarrelsome behavioural responses, and
grandiosity amplified within-person associations
between perceived dominance, negative affect, and
quarrelsome behavioural responses.
Associations held after controlling for additional
personality disorder features (e.g., Antisocial Personality
Disorder), participant sex, and age.
Note: NPI = Narcissistic Personality Inventory, PNI/G = Pathological Narcissism Inventory Grandiosity Scale, CNS = Childhood Narcissism Scale, SIDP-IV = Structured Interview for DSM-IV Personality.
S. R. COLEMAN ET AL.
Table 3. Continued.
HEALTH PSYCHOLOGY REVIEW
23
participants low in NPI grandiosity, participants high in NPI grandiosity cycled a greater distance
during the ‘high identifiability’ test. This evidence demonstrates a plausible association between
grandiosity and stress-related increases in physical activity under conditions of social evaluative
threat. However, this body of research is clearly limited and should be interpreted with caution
until replicated.
In summary, grandiosity has been associated with a variety of altered stress responses, including
potentially maladaptive responses such as heightened negative affect and aggression, and potentially inconsistent activation of the autonomic nervous system. On the other hand, some of the evidence presented also suggests grandiosity may be associated with potentially adaptive responses
under certain conditions (e.g., increases in self-esteem and physical exertion in response to rejection
and social evaluative threat respectively). Most importantly, the evidence reviewed demonstrates
that grandiosity has indeed been broadly associated with a variety of health-related stress responses,
which suggests grandiosity may constitute an aspect of personality with the potential to impact physical health outcomes over time. Furthermore, these results also highlight several important factors
that may need to be considered in future studies, including the potential moderating influences of
sex/gender and characteristics of interaction partners (i.e., relative status, agency, and/or communion), as well as potential covariates such as anxious attachment, trait anger, self-deceptive selfenhancement, and additional features of personality disorders.
Associations between vulnerability and stress-reactivity
Psychological reactivity
Preliminary evidence suggests vulnerability may influence health-related psychological stress
responses; however, the available evidence appears to be limited. In one study, vulnerability was
assessed with the Hypersensitive Narcissism Scale (HSNS; Hendin & Cheek) before participants completed a bogus ‘general knowledge quiz’ (Malkin, Barry, & Zeigler-Hill, 2011; Table 4). Participants
were given either positive, negative, or no feedback about their scores. HSNS vulnerability was not
associated with affective reactivity following negative feedback, but was associated with increased
shame following positive feedback. Similarly, Atlas and Them (2008) demonstrated associations
between HSNS vulnerability increased negative affect following positive feedback on a public
speech (Table 4). HSNS vulnerability has also been associated with increased negative affect and perceived somatic activity (i.e., weakness, dizziness, sweating, shaking, trembling, muscle tension, and/or
hear rate) in response to imagining romantic infidelity and rejection (Besser & Priel, 2009); however,
these associations became non-significant after controlling for attachment anxiety (Table 4), which
suggests interpersonal hypersensitivity (i.e., a shared feature of attachments anxiety and vulnerability) may account for why individuals high in vulnerability exhibited heightened reactivity to rejection. In another study, participants completed the Pathological Narcissism Inventory (PNI; Pincus
et al., 2009) before imagining a romantic infidelity and rejection scenario or an achievement
failure scenario, and investigators examined associations between affective responses and facets
of the PNI vulnerability scale (Besser & Priel, 2010; Table 4). The facet ‘Contingent Self-Esteem’ (characterised by unstable self-esteem that depends upon external sources of validation and approval) was
associated with increased anger and negative affect following imagined rejection, but not achievement failure. Importantly, the association between contingent self-esteem and heightened increases
in anger and negative affect following imagined rejection held after controlling for neuroticism,
which is a Big Five trait characterised by self-consciousness and emotional instability that shares a
large portion of variance with the higher order dimension of vulnerability (Miller et al., 2018). The
facets ‘Hiding the Self’ (characterised by experiencing shame and anxiety over having needs for recognition and admiration and a tendency to hide these needs from others) and ‘Devaluing’ (a tendency to avoid and/or devalue others who do not provide needed recognition and admiration)
were not associated with affective responses to imagining either scenario. On the other hand,
Besser and Zeigler-Hill (2010) demonstrated that PNI vulnerability (i.e., overall, averaging across
24
Vulnerability
measure
Authors
Study design
Sample characteristics
Atlas and
Them
(2008)
Experimental
N = 106; 52.83% women,
undergraduate (age not
reported)
HSNS
Besser and
Priel (2009)
Experimental
N = 88; 56.82% women;
Mage = 24.07, SD = 2.46,
range = 20–29
HSNS
Besser and
Priel (2010)
Experimental
N = 448; 51% women;
Mage = 25.09, SD = 2.23,
range 20–30
CSE
HS
DEV
Besser and
Zeigler-Hill
(2010)
Experimental
N = 600; 50% women;
Mage = 24.07, SD = 2.25,
range = 20–30
PNI/V
Stressor/Assessment of stress-reactivity
Findings
Social evaluative threat: Participants delivered a speech that was
videotaped and ‘evaluated’ by two judges. Participants then received
one of three types of feedback: (1) positive ratings from both judges,
(2) negative ratings from both judges, or (3) judges gave mixed
ratings. A negative emotions composite (‘angry at self’, ‘guilty’, ‘selfcritical’, and ‘worthless’) was assessed before the speech and after
receiving feedback.
Rejection: Participants read a romantic rejection scenario that
involved finding one’s partner having sexual relations with another
person. Composite negative emotion (anxiety, dysphoria, and
hostility), anger, and a perceived somatic activity (weakness, dizziness,
sweating, shaking/trembling, muscle tension, restlessness, and
increased heart rate) were assessed before and after reading the
scenario.
Affect: Vulnerability was not associated with changes in negative
affect following mixed or negative feedback, but was associated with
increased negative affect following positive feedback.
Association held after controlling for baseline internalised negative
emotions.
Achievement failure: One quarter of the participants read a highthreat achievement failure scenario (being passed over for a desired
promotion at work) and one quarter read a low-threat scenario (the
company secretary retires with no threat to the participant’s job).
Rejection: One quarter of the participants read a high-threat
romantic rejection scenario (finding one’s partner having sexual
relations with another person) and one quarter read a low-threat
scenario (finding one’s partner alone in the house while something
sexually explicit plays on the television in another room).
A negative emotion composite (anxiety, dysphoria, and hostility) and
anger were assessed before and after reading the scenarios.
Achievement failure: One quarter of the participants read a ‘private’
achievement failure scenario (being pulled aside by a professor and
told that one’s class presentation was horrible and would receive a
Affect: Vulnerability was associated with increased negative emotion
and anger after imagined rejection.
No interaction with attachment anxiety.
Association between vulnerability and anger became nonsignificant
after controlling for attachment anxiety.
Perceived somatic activity: Vulnerability was associated with
increases in perceived somatic activity after imagined rejection.
No interaction with attachment anxiety.
Association held after controlling for baseline perceptions of somatic
activity, but became nonsignificant after controlling for attachment
anxiety.
Affect: CSE was associated with greater increases in anger and
negative emotion after imagined rejection, but not achievement
failure. HS and DEV were not associated with affective reactivity.
Type of threat scenario (achievement failure vs. rejection) moderated
associations between vulnerable traits and affective reactions.
No interaction with gender.
Associations held after controlling for baseline negative emotion and
neuroticism.
Affect: Vulnerability was associated with greater negative emotion
after imagining achievement failure or rejection occurring in private,
but not public.
S. R. COLEMAN ET AL.
Table 4. Summary of articles examining associations between vulnerability and psychological stress responses.
Malkin et al.
(2011)
Experimental
N = 132; 22.73% women;
Mage = 16.81, SD = .81,
range = 16–19
HSNS
Zeigler-Hill
and Besser
(2013)
Daily Diary
N = 372; 80.1% women;
Mage = 20.3, SD = 2.59
PNI/V
failing grade), and one quarter read a ‘public’ scenario (the professor
announces to the entire class that the presentation was horrible and
would receive a failing grade).
Rejection: One quarter of the participants read a ‘private’ rejection
scenario (being pulled aside at a party by one’s romantic partner and
told that he/she is having an affair and is leaving the relationship), and
one quarter read a ‘public’ scenario (one’s partner announces the
infidelity and break-up in front of everyone at a party).
A negative emotion composite (anxiety, dysphoria, and hostility) was
assessed before and after reading the scenarios.
Social evaluative threat: Participants were presented with a general
knowledge quiz’. Researchers ‘scored’ their quizzes and provided
handwritten positive, negative, or no feedback. State anxiety and
shame were assessed before the quiz and after receiving feedback.
Daily experiences: At the end of each day for seven days, participants
recorded positive and negative interpersonal events and positive and
negative achievement events via online survey. State self-esteem was
assessed at each survey.
Type of threat scenario (public vs. private) moderated associations
between vulnerability and affective reactions.
Associations held after controlling for baseline composite negative
mood.
Note: HSNS = Hypersensitive Narcissism Scale, CSE = Pathological Narcissism Inventory Contingent Self-Esteem subscale, HS = Pathological Narcissism Inventory Hiding the Self subscale, DEV = Pathological Narcissism Inventory
Devaluing subscale, PNI/V = Pathological Narcissism Inventory Vulnerability Scale.
HEALTH PSYCHOLOGY REVIEW
Affect: Vulnerability was not associated with changes in state anxiety
following evaluative feedback, but was associated with increases in
shame following evaluative feedback.
Stressor type moderated association (participants high in vulnerability
exhibited increased shame following positive feedback).
Association held after controlling for trait self-esteem.
Self-perception: Vulnerability was not associated with changes in
self-esteem in response to daily negative interpersonal events or daily
achievement events (positive or negative). On days when more
positive interpersonal events occurred, participants scoring high in
vulnerability exhibited greater increases in self-esteem compared to
low scoring participants.
25
26
S. R. COLEMAN ET AL.
facets) was associated with greater increases in negative affect in response to imagining private rejection or achievement failure scenarios, but not public scenarios (Table 4). Finally, one daily diary study
found no association between PNI vulnerability and changes in self-esteem in response to negative
interpersonal events or positive or negative achievement events (Zeigler-Hill & Besser, 2013; Table 4).
However, on days when more positive interpersonal events occurred, individuals high in PNI vulnerability exhibited greater increases in self-esteem compared to individuals low in PNI vulnerability.
Importantly, careful review of this evidence suggests associations between vulnerability and psychological stress responses may hold after controlling for trait self-esteem and neuroticism, but attachment anxiety may be an individual difference that helps explain associations between vulnerability
and psychological stress responses. As such, attachment anxiety may be a particularly important covariate to include in future studies, especially given the evidence presented above that suggests
attachment anxiety may also help explain associations between grandiosity and stress-reactivity
(Chester & DeWall, 2015).
Biological reactivity
Only one study was identified that examined associations between vulnerability and biological reactivity (Table 5). HSNS vulnerability was associated with heightened heart rate during a mock job interview, but was unrelated to changes in respiratory sinus arrhythmia (RSA) (Zhang et al., 2015).
Importantly, increases in heart rate tend to correspond with decreases in heart rate variability
(Kazmi et al., 2016). Because RSA is heart rate variability in synchrony with respiration, the finding
that HSNS vulnerability could simultaneously associate with increases in heart rate while being uncorrelated with changes in RSA may suggest that like grandiosity, vulnerability could involve an inconsistent biological stress response. However, it is important to point out that these associations were
based on zero-order correlations between HSNS vulnerability and change scores. Since these associations do not control for heterogeneity between subjects (e.g., by controlling for baseline heart rate
in regression models), they must be interpreted with great caution.
Behavioural reactivity
Finally, one study examined associations between vulnerability stress-related changes in behaviour
(Table 6). In an ecological momentary assessment study, Roche et al. (2013) observed a significant
four-way interaction between (1) PNI vulnerability, (2) PNI grandiosity, and perceptions of interaction
partners’ (3) agency and (4) communion. Participants high in PNI vulnerability reported increasing
their own agentic behaviour (i.e., status/dominance posturing) during daily social interactions, but
only if they were simultaneously high in PNI grandiosity and perceived their interaction partners
as relatively high in both agency and communion (i.e., dominant, but also friendly and likeable). In
contrast, when interaction partners were perceived as high in agency and low in communion (i.e.,
Table 5. Summary of articles examining associations between vulnerability and biological stress responses.
Authors
Zhang et al.
(2015)
Study design
Quasiexperimental
Sample
characteristics
N = 227; 82.8%
women, Mage =
19.9, SD = 1.01,
range 17–23
Vulnerability
measure
HSNS
Stressor/Assessment of
stress-reactivity
Social evaluative threat:
Participants were
videotaped performing a
mock job interview and told
the tapes would be
evaluated by experts. HR
and RSA were monitored
continuously.
Findings
HR: Vulnerability was
associated with
increased HR during
the interview.
Based on zero-order
correlations.
RSA: Vulnerability
was not associated
with RSA reactivity.
Based on zero-order
correlations.
Note: HSNS = Hypersensitive Narcissism Scale. Abbreviations for indicators of biological reactivity: HR = Heart Rate, RSA = Respiratory Sinus Arrhythmia.
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Table 6. Summary of articles examining associations between vulnerability and behavioural stress responses.
Authors
Study design
Roche
et al.
(2013)
Ecological
Momentary
Assessment
Sample
characteristics
N = 184; 66%
women, Mage =
19.3, SD = 2.8,
range = 18–54
Vulnerability
measure
PNI/V
Stressor/Assessment of
stress-reactivity
Daily interpersonal
experiences: For seven
days, participants completed
paper diaries for each faceto-face interaction lasting
more than five minutes (up
to eight diaries per day). For
each diary, participants
indicated their perceptions
of interaction partners’
agency (e.g., dominance)
and communion (e.g.,
friendliness), as well as their
own agentic and communal
behaviour. Aggressive
behaviours were defined as
high agentic responses to
perceived ‘status threats’
(i.e., perceiving high agency
in another) or high agentic
or low communal responses
to ‘rejection threats’ (i.e.,
perceiving high agency and/
or low communion in
another).
Findings
Aggression: Vulnerability
was associated with
aggressive responses to
interpersonal experiences,
but only for participants
simultaneously high in
grandiosity.
Partner characteristics and
grandiosity moderated
associations (participants
high in PNI grandiosity and
low in PNI vulnerability who
perceived simultaneously
high agency and communion
in an interaction partner
reported greater increases in
agency; participants who
were simultaneously high in
PNI grandiosity and PNI
vulnerability who perceived
high agency and communion
in an interaction partner
reported greater increases in
agency; participants
simultaneously high in PNI
grandiosity and PNI
vulnerability who perceived
high agency and low
communion in an interaction
partner reported greater
decreases in agency).
Note: PNI/V = Pathological Narcissism Inventory Vulnerability Scale.
cold, unfriendly), participants high in PNI vulnerability and grandiosity reported decreasing their own
agentic behaviours. There was no main effect of vulnerability on reported agentic behaviour during
daily social interactions, and agentic behavioural responses to individuals high in agency and communion were most pronounced for participants high in grandiosity and low in vulnerability. Together,
these results suggest that perceptions of agency and communion in social interaction partners may
influence associations between vulnerability and aggression, but such associations may also depend
on relative levels of grandiosity within an individual. More importantly, the overall limited available
evidence examining associations between vulnerability and health-related stress-reactivity highlights
an important theoretical and empirical gap in this body of literature.
Discussion
At the broadest level, this review demonstrated that narcissism (encompassing grandiosity and vulnerability) has been broadly associated with health-related stress-reactivity. We see relatively consistent patterns that grandiosity and vulnerability have been independently and differentially associated
with a variety of potentially maladaptive stress responses. However, considerable nuance in these
associations appears to exist (e.g., what contexts/stressors, what indicators of stress-reactivity,
whether additional individual difference variables were examined), and under certain stressful conditions narcissism (particularly grandiosity) may confer some level of resilience. Importantly, the Contemporary Clinical Model of Pathological Narcissism (Pincus et al., 2015), the Dynamic Self-Regulatory
Processing Model of Narcissism (Morf, 2006), and the Narcissism Spectrum Model (Krizan & Herlache,
2018) all posit that grandiosity and vulnerability may oscillate or co-occur within individuals, and
28
S. R. COLEMAN ET AL.
related empirical evidence has supported this position (e.g., Dowgwillo, Dawood, Bliton, & Pincus,
2018; Giacomin & Jordan, 2014, 2016; Gore & Widiger, 2016; Hyatt et al., 2018; Li et al., 2016). As
such, narcissism could broadly encompass a spectrum of altered stress responses that oscillate or
co-occur within individuals. More generally, this review is an important first step towards clarifying
and understanding associations between narcissism and health-related stress-reactivity by highlighting theoretical and empirical gaps in the existing literature. Additionally, this work informs future
research; for example, it underscores the importance of measuring grandiosity and vulnerability simultaneously, carefully selecting and controlling for related individual difference variables, and examining relevant moderators. As more research on this topic accumulates, the study of relationships
between dimensions of narcissism, stress, and related health processes may contribute to the
ongoing development of theories of narcissism and individual differences, and how such factors
may ultimately influence physical health outcomes.
This review suggests that the type stressor may be an important determinant of how individuals
higher in dimensions of narcissism react to stress. In particular, stressors that threaten self-concept
and/or involve a motivated performance component (e.g., social evaluative threat, interpersonal
rejection, competitive tasks) seem to be especially relevant to individuals high in grandiosity or vulnerability, which is in accordance with theory and related evidence (Krizan & Herlache, 2018; Morf &
Rhodewalt, 2001; Pincus & Lukowitsky, 2010; Pincus et al., 2015). As noted in the introduction, individuals attend to threatening stimuli in the environment by appraising the potential for a stimulus to
cause harm or loss (e.g., to some basic necessity) and evaluating their own personal coping resources
for managing the stimulus (Lazarus & Folkman, 1984). Stress results when the potential for harm or
loss exceeds one’s coping resources. Because the need for recognition and admiration is of central
importance for individuals higher in dimensions of narcissism, and such individuals exhibit deficits
in their ability to self-regulate when needs for recognition and admiration are threatened, it makes
sense that self-concept threats and/or competitive tasks might catalyse heightened stress responses.
In contrast, stressors that model anticipatory threat may not produce significant (or consistent) effects
of narcissism dimensions on stress responses. For example, in the studies reviewed that used the
countdown-to-an-aversive-stimulus paradigm (i.e., Kelsey et al., 2001; Sylvers et al., 2008), grandiosity
was generally not associated or inconsistently associated with stress-reactivity. Given that the
majority of studies utilising stressors explicitly intended to threaten self-concept, and these studies
observed associations between grandiosity and heightened stress-reactivity, it may be that grandiosity is not sufficiently threatened by the countdown-to-an-aversive-stimulus paradigm. However, one
might also speculate that under conditions of anticipatory threat, grandiosity may confer some
degree of resilience. For example, Kelsey et al. (2001) posited that their results might suggest grandiosity involves enhanced and sustained vigilant readiness, but faster emotional disengagement and/
or habituation to aversive stimuli. As such, individuals higher in grandiosity could have some advantages with respect to stress responses under real-world conditions of anticipatory threat (e.g., the
time leading up to a public speech). Of course, this hypothetical scenario is speculative, but it
poses interesting questions for future research (e.g., using naturalistic methods such as ecological
momentary assessment).
It is interesting to consider the possibility that a stereotypically negative aspect of personality such
as grandiosity may facilitate adaptive stress responses under certain circumstances. For example,
men and women high in grandiosity may experience decreases in negative emotion and increases
in self-worth following negative feedback (i.e., Atlas & Them, 2008; Nicholls & Stukas, 2011, respectively), and men high in grandiosity (particularly those who distort their romantic histories to be more
positive) may have some resistance to changes in self-esteem following romantic rejection (Rhodewalt & Eddings, 2002). Similarly, individuals high in grandiosity may have relatively stable self-esteem
in response to negative interpersonal experiences (Geukes et al., 2017; Zeigler-Hill & Besser, 2013),
particularly individuals high in the traits ‘leadership/authority’ and ‘grandiose exhibitionism’
(Zeigler-Hill & Besser, 2013). Additionally, there is some evidence that social evaluative threat may
catalyse increases in physical exertion during exercise for individuals high in grandiosity
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(Woodman et al., 2011). Overall, this evidence suggests it is possible that certain aspects of narcissism
may confer health benefits under certain conditions (particularly the leadership/authority facet of
grandiosity, which has been associated with other adaptive processes, such as drive/goal-persistence;
Ackerman et al., 2011). Interestingly, prior research has correlated grandiosity with a variety of selfreported adaptive coping strategies, including self-controlling and positive reappraisal (Birkás
et al., 2016), and the evidence presented in this review may point to stress responses potentially
linking grandiosity to adaptive coping.
That said, much of the evidence reviewed indicates that grandiosity has been broadly associated
with potentially maladaptive stress responses, including over- and under-reactive biological
responses that may contribute to poor health outcomes such as obesity, impaired immune response,
and cardiovascular disease (Carroll et al., 2009). Just as research has demonstrated correlations
between grandiosity and self-reported use of adaptive coping strategies, it is not unreasonable to
speculate that individuals higher in grandiosity may have inaccurate appraisals of their personal
coping resources, or intentionally report coping styles they perceive to be more socially desirable.
Importantly, stress responses that fail to promote accurate appraisals of threat and/or personal
coping resources will likely not facilitate behavioural adjustments necessary for effective coping.
To make a hypothetical example of how impairments in stress-related appraisals may negatively
impact the long-term health of individuals high in grandiosity, consider research demonstrating
that individuals high in grandiosity may lose social support over time due to being seen by others
as increasingly arrogant and aggressive (Leckelt, Küfner, Nestler, & Back, 2015; Paulhus, 1998).
Whereas vulnerability involves interpersonal hypersensitivity and defensiveness (i.e., processes that
could lead to intermediate outcomes that have been associated with increased mortality risk, such
as social isolation and loneliness; Holt-Lunstad, Smith, Baker, Harris, & Stephenson, 2015), one
might suggest that grandiosity involves impairments in stress-related appraisal processes (e.g., distorting ones past relationships to be more positive to buffer self-esteem in the face of interpersonal
rejection; Rhodewalt & Eddings, 2002) that could make it difficult to adjust behaviour to stop the loss
of social support or prevent future rejection. Over time, such impairments could also lead to loneliness and/or social isolation. Again, this hypothetical scenario is speculative, and research is needed to
determine whether (and how) grandiosity (and vulnerability) influences physical health over time.
More importantly, regardless of whether narcissism dimensions confer health risks or benefits over
longer periods of time, this review suggests dimensions of narcissism have been broadly associated
with a variety of health-related stress responses. However, there appear to be important theoretical
and empirical gaps to address in future research to advance our understanding of how narcissism
ultimately impacts stress and health processes.
Gaps in the literature and suggestions for future research
Perhaps the most important gap in this literature is the lack of evidence directly linking narcissism to
stress-related physical health outcomes, such as the onset and progression of chronic disease.
Aspects of personality related to narcissism, such as cynical hostility and trait anger and aggression
have been studied over many decades and associated with important physical health outcomes, such
as cardiovascular disease. A primary goal for future research should be to examine associations
between dimensions of narcissism and physical health outcomes, including both pre-clinical and
clinical outcomes, and making use of epidemiological methods and/or longitudinal designs to understand how narcissism associates with chronic disease in the general population over time. In working
towards a comprehensive and theoretically cohesive understanding of how narcissism influences
stress and related physical health outcomes, stress and health researchers may want to consider
incorporating assessments of trait grandiosity and vulnerability into their research (e.g., the Narcissistic Personality Inventory and Hypersensitive Narcissism Scale respectively) in addition to assessments
of pathological narcissism, such as the PNI or it’s short-form version, the Brief-Pathological Narcissism
Inventory (Schoenleber, Roche, Wetzel, Pincus, & Roberts, 2015). Including a comprehensive baseline
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S. R. COLEMAN ET AL.
assessment of narcissism dimensions (i.e., normal and pathological variants) may be particularly
important given evidence presented in this review that suggests normal and pathological variants
of grandiosity may differentially associate with health-related stress responses (e.g., Kelsey et al.,
2001 vs. Sylvers et al., 2008).
A notable inconsistency across studies appears to be the selection of theoretically and empirically
relevant covariates and moderators. This issue is particularly important given the ongoing debate
about the structure and measurement of narcissism. For example, in contrast to the two-dimensional
representation of narcissism (i.e., grandiosity/vulnerability), some narcissism researchers favour a threefactor representation to cover the many measures of narcissistic grandiosity and vulnerability, whereby
measures of grandiosity primarily capture extraverted and exhibitionistic themes, measures of vulnerability primarily capture neurotic themes, and both grandiosity and vulnerability share common themes
of disagreeableness and antagonism, potentially indicating a common factor of entitled self-importance (Krizan & Herlache, 2018; Wright & Edershile, 2018). Regardless of whether a two-dimensional
or three-factor representation of narcissism is preferred, evidence suggests that disagreeable/antagonistic aspects of narcissism may play an important role in associations between grandiosity and stressreactivity (e.g., contributing to greater decreases in self-esteem following stressful social interactions;
Geukes et al., 2017), and neuroticism has been found to correlate relatively highly with vulnerability
(Miller et al., 2018). As such, it is likely important for investigators to routinely control for agreeableness
and neuroticism as well as extraversion in order to make stronger conclusions about the unique effects
of grandiosity and vulnerability on stress responses. However, our review of the existing literature indicates that studies have inconsistently controlled for these factors. Similarly, our review suggests trait
anger and attachment anxiety may also constitute important covariates and/or moderators. For
example, individuals higher in grandiosity may be prone to anger, and consequently, exhibit heightened anger responses to stress (Bond et al., 2006), and individuals higher in vulnerability may be
prone to interpersonal hypervigilance and fears of abandonment (i.e., attachment anxiety) and
exhibit heightened affective responses and greater somatic activation following interpersonal rejection
(Besser & Priel, 2009); however, studies appear to inconsistently control for these factors. Furthermore,
when clinical measures of narcissism are used, it may be important to control for related aspects of personality pathology, such as symptoms of Borderline and Antisocial Personality Disorders. More generally, the careful, theoretically informed selection of relevant additional individual differences to examine
as potential covariates and/or moderators will help future investigators make stronger conclusions
about how grandiosity and vulnerability influence stress-reactivity.
It may also be important for investigators to carefully consider self-deceptive self-enhancement
strategies that may arise in response to specific stressors and buffer associations between narcissism
dimensions and stress-reactivity. For example, given evidence that distorting one’s romantic history
to be more favourable could buffer an association between grandiosity and changes in self-esteem
following romantic rejection (Rhodewalt & Eddings, 2002), an experiment using a public speaking
task may benefit from including pre- and post-stress assessments of past public speaking performance and examine whether changes on such assessments moderate associations between grandiosity and stress-reactivity. Moreover, in light of evidence that gender/sex (e.g., Edelstein et al., 2010) and
age may influence associations between grandiosity and stress responses (e.g., blunted cortisol
responses in children, Bukowski et al., 2009; heightened cortisol responses in adult males, Edelstein
et al., 2010), investigators may also benefit from examining the moderating effects of gender/sex
and/or age whenever possible. Most importantly, the results of this review highlight the need to
select relevant covariates and moderators to not only better understand how dimensions of narcissism associate with stress responses, but also to avoid the risk of committing Type I errors, promote
future replication, and contribute meaningfully to the ongoing debate over the structure and assessment of narcissism.
Another important empirical gap in the literature is the relative lack of studies using within-person
methods to study how narcissism dimensions influence stress-reactivity. In studies on narcissism and
stress-reactivity, the temporal sequencing of assessments is particularly important for making causal
HEALTH PSYCHOLOGY REVIEW
31
inferences given evidence that narcissism dimensions may fluctuate in response to external events
(e.g., states of grandiosity may be lower on days when people experience greater stress; Giacomin
& Jordan, 2016). Only 29/747 screened articles met our inclusion criteria; however, an additional
four articles were very close. One study demonstrated that in men, NPI grandiosity was associated
with heightened aggression and greater increases in testosterone in response to a competitive
task that involved delivering a noise blast to an opponent after winning, and receiving a noise
blast after losing, but HSNS vulnerability was not associated with changes in aggression or testosterone (Lobbestael, Baumeister, Fiebig, & Eckel, 2014). Another study demonstrated that men scoring
high on the PNI full-scale (which is categorised as a measure of vulnerability in Grijalva et al.,
2015) exhibited increases in testosterone in response to a neutral money handling and financial
risk-taking task (i.e., sorting $1,600 in fake money into 80 piles of $20 bills, then playing 10 lotteries
with real monetary outcomes, each with a safe and a risky option), and men scoring low on the PNI
full-scale exhibited decreases in testosterone (Stenstrom, Dinsmore, Kunstman, & Vohs, 2018). In contrast, in response to handling real money before playing the lottery, men scoring low on the PNI fullscale exhibited larger increases in testosterone relative to men scoring high on the PNI full-scale.
Unfortunately, both studies administered narcissism measures at the end of the protocols, and the
direction of causality was not able to be determined with confidence in either case. Similarly, one
EMA study demonstrated that NPI grandiosity was associated with increased salivary cortisol and
alpha-amylase on days when individuals reported greater negative affect (presumptively reflecting
stress-reactivity; Cheng, Tracy, & Miller, 2013). However, negative affect was assessed at the end of
each day, leaving results prone to recall bias and distortion. Finally, one daily diary study found
that compared to individuals low in NPI grandiosity, individuals high in NPI grandiosity reported
lower self-esteem and more negative impressions of the day on days when more negative interpersonal events occurred (Zuckerman & O’Loughlin, 2009). However, it was not clear whether appropriate statistical controls (e.g., time-lagged analyses) were applied to allow for causal inferencing. Of
course, these studies are theoretically informative. However, in order to determine effect sizes in
future empirical reviews on the current topic, more research is needed that adheres to the sequence
of administering measures of narcissism and pre-stress states at baseline, followed by stressor
exposure, followed by assessments of post-stress states.
A third important gap is the relative omission of biological processes in theories of the development and maintenance of narcissism. For example, the Dynamic Self-Regulatory Processing Model
posits that genetics may play a role in the construction and maintenance of narcissism (Morf,
2006), and the Narcissism Spectrum Model (Krizan & Herlache, 2018) discusses very generally evidence for biobehavioural motivational systems governing tendencies towards dominance and assertion and responses to rewards and punishments, but neither model seems to account for how
dynamic biological stress responses could maintain or even potentiate narcissism. Studies have
shown that biological stress-reactivity (e.g., changes in heart rate variability) is important for promoting self-regulatory control (Segerstrom & Nes, 2007). Thus, it may be reasonable to speculate that dysregulation or inconsistent activation of biological stress response systems may underlie selfregulatory deficits associated with narcissism, such as difficulty regulating self-concept, emotion,
and behavioural responses when grandiosity is threatened. As such, the incorporation of biological
stress-reactivity into theories of narcissism may provide a useful, additional framework to help
guide future research.
Finally, in comparison to research examining associations between grandiosity and psychological
stress-reactivity, research on associations between narcissism dimensions and biological and behavioural stress-reactivity is extremely limited, particularly with respect to vulnerability. Examining biomarkers in addition to self-reported changes in stress and affect may be particularly useful when
studying narcissistic individuals, who are by definition highly motivated to provide socially desirable
responses. Additionally, future research examining multiple biomarkers of stress simultaneously
would be useful for further exploring the possibility that narcissism dimensions may be associated
with deficiencies in biological stress-reactivity, similar to other types of personality pathology
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S. R. COLEMAN ET AL.
characterised by emotionality and aggression (e.g., one review highlighted that antisocial tendencies
have been associated with simultaneous reductions in heart rate and heart rate variability; Beauchaine, 2001). Regarding behavioural stress-reactivity (and coping), many health behaviours such
as diet, exercise, and smoking may be influenced by stress, and associations between narcissism
dimensions and stress-related changes in alcohol consumption and sexual behaviours may be particularly important to examine since these factors have been cross-sectionally associated (e.g.,
Agrawal, Narayanan, & Oltmanns, 2013; Martin, Benotsch, Lance, & Green, 2013). Because it is very
difficult (or impossible) to examine changes in patterns of alcohol use or sexual behaviour in a laboratory setting, naturalistic methods, such as ecological momentary assessment, may be useful for
examining how narcissism dimensions associate with such behaviours in daily life. To this end, ecological momentary assessment may be especially useful for helping to reduce recall and social desirability biases by examining behaviours close in time to when they naturally occur (Conner, Tennen,
Fleeson, & Barrett, 2009; Smyth & Stone, 2003).
Limitations
The evidence presented in this review must be interpreted within the context of important limitations. First, most of the studies reviewed utilised the Narcissistic Personality Inventory (NPI) as the
primary or only measure of narcissism (see Tables 1–3, ‘Grandiosity Measure’ columns). Although
the NPI is thought to broadly capture grandiosity, it has been criticised for problems with its factor
structure and construct validity (Ackerman et al., 2011; Rosenthal & Hooley, 2010). That said, the
NPI has been correlated with expert ratings of Narcissistic Personality Disorder trait profiles (Miller,
Price, & Campbell, 2012), and this review demonstrated that the NPI has been generally associated
with altered stress-reactivity in accordance with theory. Like the NPI, the construct validity of the
Pathological Narcissism Inventory (PNI) grandiosity scale has been called into question. The PNI
grandiosity scale is missing an exhibitionistic component, which is an important facet of grandiosity
(Wright & Edershile, 2018). Additionally, the PNI grandiosity scale and has been found to exhibit factor
loadings and correlational patterns more consistent with expert conceptualizations of narcissistic vulnerability (e.g., Miller et al., 2011, 2016). However, a recent study demonstrated that by simultaneously including the PNI grandiosity and vulnerability scales in regression models (as
investigators did in the studies currently reviewed; Besser & Zeigler-Hill, 2010; Roche et al., 2013;
Zeigler-Hill & Besser, 2013), associations between PNI grandiosity and other personality variables
more closely match expert conceptualizations of grandiosity (e.g., positive association with extraversion, negative association with neuroticism; Edershile et al., 2018). Overall, future investigators should
be aware that utilising the NPI and/or the PNI could be missing, underestimating, or conflating key
associations between grandiosity and stress-reactivity. Furthermore, investigators should take care to
use appropriate statistical controls when using the PNI to make more confident conclusions about
how grandiosity associates with stress responses and other health processes (i.e., simultaneously
include the grandiosity and vulnerability scales in statistical models to account for their overlapping
variance), and/or examine if this was done in others’ work/analyses. Conversely, investigators may
want to consider using measures of grandiosity that are relatively less controversial in addition to
measures that have had their construct validity called into question and have since been heavily
debated. Potential additional assessments of grandiosity could include the Narcissistic Grandiosity
Scale (Rosenthal, Hooley, & Steshenko, 2007) or the narcissism subscales of the Dirty Dozen
(Jonason & Webster, 2010) or Short Dark Triad (Jones & Paulhus, 2014). Another limitation was the
inability to provide an in-depth analysis of how measures of entitlement/exploitativeness have
associated with stress responses. Recent reviews have proposed that entitlement/exploitativeness
may broadly contribute to psychological distress (Grubbs & Exline, 2016), and measures of entitlement/exploitativeness may encompass both grandiose and vulnerable themes and could potentially
be treated as capturing a distinct dimension of narcissism or a common middle ground linking
grandiosity and vulnerability (Krizan & Herlache, 2018; Wright & Edershile, 2018). The only measure
HEALTH PSYCHOLOGY REVIEW
33
specific to entitlement/exploitativeness in the current review was the ‘Entitlement/Exploitativeness’
subscale of the NPI, which is associated with grandiose themes. As such, we categorised this subscale
as a measure of grandiosity based on the systematic categorisation contained in Grijalva et al. (2015).
As more research examines how additional measures of entitlement/exploitativeness associate with
various stress responses, it will be useful to examine how entitlement/exploitativeness generally
associates with stress-reactivity.
Finally, although features of systematic review methodology were utilised to identify studies for
inclusion in this review, we did not solicit unpublished data from other investigators. Given the
breadth of this topic and heterogeneity of factors under examination, we thought it premature to
conduct a meta-analysis or systematic review at this time as in our view such reviews are most valuable when there are large numbers of high quality studies using similar methods and measures.
Moreover, an empirical review examining associations between narcissism and a specific stress
response for which there may be sufficient unpublished data would likely be redundant with existing
reviews (e.g., Baumeister et al., 2000; Bosson et al., 2008; Rasmussen, 2016). For these reasons, we
opted for a narrative review of the existing literature as it allows for a more nuanced discussion of
existing relationships between narcissism dimensions and various stress responses. However, we
acknowledge that there may be high quality unpublished data, and that not soliciting unpublished
data opens our review to the criticism of publication bias. After more research on this topic accumulates, reviews would benefit from soliciting unpublished materials to determine more empirically the
effects of narcissism dimensions on stress-reactivity.
Conclusion
In conclusion, this review demonstrated that there is accumulating and generally consistent evidence
that narcissism dimensions may contribute to altered stress-reactivity. As such, this review contributes to the growing body of literature suggesting that narcissism may constitute a health-relevant
aspect of personality. Some of the evidence presented suggests that under certain stressful conditions, grandiosity may confer resilience, and thus contribute to better health outcomes.
However, the larger pattern of results seems to indicate that both grandiosity and vulnerability
have broadly associated with a variety of potentially maladaptive stress responses. Maladaptive
stress-reactivity, particularly when repeated often and over long periods, may cause wear-and-tear
on bodily systems that ultimately hasten disease onset and progression (McEwen, 1998; Smyth
et al., 2013). In addition to continuing to refine and replicate findings examining the links between
narcissism dimensions and various stress responses, the association of narcissism dimensions with
physical health outcomes is worth examining. Narcissism researchers should consider incorporating
assessments of physical health status into their work, and stress and health researchers interested in
studying narcissism should consider using sophisticated methods (e.g., longitudinal designs, ecological momentary assessment) to understand the health correlates of narcissism across different populations and as they unfold over time and contexts. Additionally, this review highlights the importance
of carefully selecting and assessing theoretically relevant factors that may help explain associations
between narcissism, stress-reactivity, and health (particularly extraversion, agreeableness, neuroticism, trait anger, attachment anxiety, features of related personality disorders, sex/gender, and
self-deceptive self-enhancement coping strategies). As this body of literature continues to grow
and extend its bounds, a better understanding of how narcissism influences stress and health may
help to identify individuals at increased risk for poor health outcomes, and eventually contribute
to the development of new strategies to promote health and well-being.
Acknowledgement
We would like to thank Dr. Jennifer E. Graham-Engeland and Dr. Hannah M. C. Schreier for feedback on an early version of
this manuscript.
34
S. R. COLEMAN ET AL.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Sulamunn R. M. Coleman
http://orcid.org/0000-0002-0460-4632
Joshua M. Smyth
http://orcid.org/0000-0002-0904-5390
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