Wednesday, 16 May 2018
Pathological narcissism and maladaptive self-regulatory behaviours in a nationally representative sample of Canadian men
Psychiatry Research Volume 256, October 2017, Pages 156-161 Author links open overlay panelDavidKealyaJohn S.OgrodniczukaSimon M.RicebcJohn L.Oliffed a Department of Psychiatry, University of British Columbia, Vancouver, Canada b Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia c Centre for Youth Mental Health, The University of Melbourne, Parkville, Australia d School of Nursing, University of British Columbia, Vancouver, Canada Received 22 November 2016, Revised 7 April 2017, Accepted 4 June 2017, Available online 15 September 2017. crossmark-logo https://doi.org/10.1016/j.psychres.2017.06.009 Get rights and content Highlights • Severity of pathological narcissism was found to be higher among younger men compared to middle-aged and older men. • Pathological narcissism was associated with alcohol and drug overuse, and aggressive and risk-taking behaviour. • The relationship between pathological narcissism and drug use was more pronounced among younger men. • The relationship between pathological narcissism and risk-taking was more pronounced among men with higher symptom distress. Abstract Clinical observation has linked externalizing coping strategies such as substance overuse and aggressive behaviours with narcissistic personality dysfunction. This study examined the relationship between pathological narcissism and maladaptive self-regulatory behaviours among Canadian men. An online survey was distributed among a stratified, nationally representative sample of 1000 men from across Canada. The survey included brief self-report measures of pathological narcissism, maladaptive externalizing coping behaviours, and general psychological distress. After controlling for the effects of age and general psychological distress, pathological narcissism was found to be significantly associated with alcohol overuse and aggressive behaviour. Significant though modest interaction effects were found between pathological narcissism and age – with regards to drug use – and distress – with regards to risk-taking behaviour. The findings point to the need for attention to narcissistic dysfunction as a clinical and public health issue among men. Previous article in issue Next article in issue Keywords Pathological narcissism Maladaptive behaviours Substance use Risk-taking behaviour Aggression Men's health 1. Introduction Narcissistic personality attributes continue to fascinate the public. The label “narcissistic” carries a profound stigma, often used to denote a self-absorbed and socially offensive individual who ultimately deserves rebuke. Yet a form of narcissism well-known to clinicians (Ogrodniczuk, 2013; Ronningstam, 2005) is associated with distress and impairment (Miller et al., 2007), and linked with other clinical concerns including interpersonal problems (Ogrodniczuk et al., 2009), depressive tendencies (Kealy et al., 2012), and suicidality (Ansell et al., 2015; Blasco-Fontecilla et al., 2009). This personality constellation, known as pathological narcissism, hinges upon distortions and fluctuations of self-image and admiration needs (Cain et al., 2008; Pincus et al., 2015; Ronningstam, 2011); severe clinical presentations are often diagnosed as narcissistic personality disorder. Where a stable but dynamic view of the self – including realistic positive appraisals – is a normal component of identity, pathological narcissism is defined by unstable and/or maladaptive regulation of self-image (Pincus and Lukowitsky, 2010; Ronningstam, 2011). Grandiose features – involving inordinate self-inflation and admiration-seeking – and vulnerable features – involving dysphoria and diminished self-esteem – often co-exist in a manner that can appear incongruous and perplexing. Indeed, while narcissistic subtypes have been described using various labels (see Cain et al. (2008) for a review), fluctuations between grandiose and vulnerable states are commonly observed (Gore and Widiger, 2016), and mixed presentations feature prominently in the clinical and theory-based literature (Caligor et al., 2015; Cooper, 2009; Kernberg, 2014; Kohut and Wolf, 1978; Kealy and Rasmussen, 2012; Levy, 2012; Pincus et al., 2014). This latter literature widely regards deficiencies and distortions of self-image as constituting the core of pathological narcissism: “narcissistic patients are desperately attempting to manage their vulnerability” (Gabbard and Crisp‐Han, 2016, p. 116). The maladaptive self-regulatory strategies of those who suffer from pathological narcissism extend beyond fantasies of brilliance and admiration. Several authors have noted that narcissistic patients may turn to externalizing, sensation-seeking behaviours in order to diminish awareness of shame-related affects or combat feelings of emptiness (Grosch, 1994; Kernberg, 1984; Kohut and Wolf, 1978). Drugs or alcohol may be employed in an attempt to neutralize painful experiences of narcissistic injury, while risk-taking behaviour (e.g., reckless driving, risky sexual activity) may contribute a sense of aliveness during times when admiring responses from others are in short supply. Kohut also described the phenomenon of narcissistic rage, wherein the individual explodes with anger and/or aggression in response to feelings of inadequacy, shame, or humiliation (Kohut, 1972). Externally directed rage is thus thought to temporarily relieve the painful affects associated with a weakened self-representation and restore a sense of potency. Partial support for the association between narcissistic features and maladaptive self-regulatory strategies can be found in the empirical literature (see Dowgwillo et al. (2016) for a review). Among college undergraduates, grandiose narcissism has been found to be associated with alcohol and drug use (Buelow and Brunell, 2014; Hill, 2015; MacLaren and Best, 2013), including binge drinking (Luhtanen and Crocker, 2005), as well as aggressive and dangerous driving (Edwards et al., 2013; Hill, 2015) and risky behaviours (Buelow and Brunell, 2014; Foster et al., 2009). Pathological narcissism, encompassing both grandiose and vulnerable features, was found to be associated with substance overuse in a sample of Iranian undergraduates (Mowlaie et al., 2016). Among student samples, aggression has been linked with both vulnerable (Fossati et al., 2010; Krizan and Johar, 2015; Lobbestael et al., 2014) and grandiose narcissism, particularly in the context of ego threat experiences (Bushman and Baumeister, 1998; Fossati et al., 2010; Lobbestael et al., 2014). Among clinical samples, narcissistic grandiosity has been associated with aggressive behaviour among both inpatient (Goldberg et al., 2007) and outpatient samples (Ellison et al., 2013). Studies investigating the relationship between narcissism and maladaptive self-regulatory behaviours in more representative community samples are comparatively scarce. Findings from the National Epidemiologic Survey on Alcohol and Related Conditions revealed associations between features of grandiose narcissism and substance use (Stinson et al., 2008), as well as reports of violent behaviour – particularly when combined with impulsive traits (Larson et al., 2015). Interestingly, community studies have found an inverse relationship between narcissism and age, with higher levels of narcissistic personality features observed among younger adults (Stinson et al., 2008). Identity-related maturational processes may contribute to reduced narcissistic dysfunction (Cramer, 2017), and perhaps to a broadening of self-regulatory strategies. Given the relatively limited perspective of narcissism assessed in previous studies, further research regarding these associations in large representative community samples is warranted. The present study examined pathological narcissism – including vulnerable elements – and maladaptive self-regulatory behaviours in a nationally representative sample of Canadian men. Examining this issue among men is particularly warranted given their higher rates of substance abuse and aggression compared to women (Archer, 2004; Brady and Randall, 1999). Our first objective was to explore the severity of narcissistic tendencies among Canadian-based men in the general community. We included age in this exploration and in subsequent analyses, due to most previous narcissism research involving young adult samples, and given previous reports of significant age differences in narcissistic dysfunction. Our second objective was to investigate the relationship between narcissistic features and men's use of unhealthy coping strategies, including drug and alcohol overuse, angry and aggressive behaviour, and risk-taking behaviour. Since these coping responses are likely to be influenced by psychological distress, we sought to control for this when examining narcissism and maladaptive self-regulatory behaviours. We hypothesized that pathological narcissism would be significantly positively associated with each of the aforementioned maladaptive behaviour domains, even after controlling for the effects of general psychological distress. Finally, we examined potential interactions between pathological narcissism, age, and psychological distress. This was an exploratory investigation regarding the potential moderating effects of age and distress on the relationship between pathological narcissism and maladaptive behaviours. 2. Methods 2.1. Sample The sample was a non-probability sample of 1000 Canadian men who took part in a national survey regarding men's mental illness, conducted in April 2016. Respondents were sourced from a Canadian online survey provider and screened regarding eligibility criteria, which consisted of being over the age of 19 years, being able to read English, and having access to the internet. Weighted randomization was then used to select respondents for the survey. Further screening was done to meet stratification quotas, in order to reflect the distribution of Canadian males by age and by region, according to 2011 national census data. Screening also removed non-completed and inappropriate (e.g. non-differential) responses (the survey software required all items to be completed). Together with stratification, this resulted in a reduction from the number of initial respondents from 1488 to a final sample of 1000 men from across Canada's regions. Participants’ age ranged from 19 through 86; the mean age was 49.6 years (SD = 14.6). The majority of men were employed, with n = 520 working full-time, n = 82 working part-time, and n = 89 self-employed. Retired men comprised nearly a quarter of the sample, n = 226. Five percent, n = 54, indicated that they were unemployed and looking for work, and n = 36 reported being unable to work due to disability. The remainder were students (n = 50), not seeking employment (n = 12), and stay-at-home parents (n = 8). Eighty-five percent of participants had been educated beyond high school, including n = 441 having obtained a university degree, n = 205 with a college or trade school diploma, and n = 204 having partial college or university education. 2.2. Procedure Ethics approval was obtained from the University of British Columbia Research Ethics Board. Following screening for eligibility and sample stratification, participants completed the online survey measures listed below. Participants were reimbursed for their time with proprietary panel points, which could later be exchanged for various rewards. 2.3. Measures 2.3.1. Pathological narcissism Pathological narcissism was assessed using the Super Brief Pathological Narcissism Inventory (SB-PNI; Schoenleber et al., 2015), a 12-item measure that was developed as a very brief version of the Pathological Narcissism Inventory (PNI; Pincus et al., 2009). The PNI assesses both grandiose and vulnerable features of pathological narcissism (a higher-order factor structure reflects these two domains), and provides a total score for overall severity of pathological narcissism (Pincus, 2013; Wright et al., 2010). Likewise, the narcissistic dysfunction assessed by the SB-PNI encompasses both grandiose and vulnerable elements. Responses to items are provided using a 6-point scale ranging from “not at all like me” (0) to “very much like me” (5). Narcissistic grandiosity is reflected in six items, such as “I often fantasize about performing heroic deeds,” “I like to have friends who rely on me because it makes me feel important,” and “I often fantasize about accomplishing things that are probably beyond my means”. The remaining six items capture narcissistic vulnerability, including “It's hard to feel good about myself unless I know other people admire me,” “When others get a glimpse of my needs, I feel anxious and ashamed,” and “I am preoccupied with thoughts and concerns that most people are not interested in me”. Due to SB-PNI grandiosity and vulnerability subscales being highly correlated in the present sample, r = 0.69, p < 0.001, and in accordance with conceptual accounts of typically intertwined grandiosity and vulnerability (Caligor et al., 2015; Kealy and Rasmussen, 2012; Ronningstam, 2011), the total pathological narcissism score was used. As with the full version of the PNI, the total score was derived from the mean of all items. The internal consistency of the SB-PNI in the present sample was excellent, with Cronbach's alpha of α = 0.92. 2.3.2. Maladaptive self-regulatory behaviours The Male Depression Risk Scale (MDRS-22; Rice et al., 2013) was used to assess maladaptive, externally-oriented self-regulatory activities. The MDRS-22 was developed to assess externalizing methods of coping with emotional difficulties that can indicate risk for depressive disorders among men. We used the four MDRS-22 subscales that tap potentially dangerous externalizing behaviours, in order to assess the following domains: drug use, alcohol use, anger / aggression, and risk-taking behaviour. The MDRS-22 uses an eight-point scale, anchored by “not at all” (0) and “almost always” (7) to assess the frequency of behaviours, referring to the previous month. The Drug Use subscale consists of three items, including “I used drugs to cope,” and “I sought out drugs”. The Alcohol Use subscale consists of four items including “I drank more alcohol than usual,” and “I needed alcohol to help me unwind”. Each of these subscales demonstrated excellent internal consistency in the present sample, with alphas of α = 0.96 and α = 0.94, respectively. The Anger / Aggression subscale is comprised of four items, including “I was verbally aggressive to others,” and “I overreacted to situations with aggressive behaviour”. This subscale also had a high degree of internal consistency, with Cronbach's alpha of α = 0.93. The Risk-taking subscale, consisting of three items including “I drove dangerously or aggressively,” and “I took unnecessary risks,” demonstrated good internal consistency, α = 0.83. Scores for each of the four domains were obtained using the mean of the items for each subscale. 2.3.3. General psychological distress General psychological distress was assessed using the K6 (Kessler et al., 2002), a six-item scale that has been widely used as a screening instrument for mood and anxiety disorders. Using a reference of the past 30 days, K6 items inquire as to how often the respondent experienced symptoms associated with anxiety and depression, including nervousness, hopelessness, and worthlessness (e.g., “About how often did you feel so depressed that nothing could cheer you up?”). The K6 is scored by summing the responses to all items, with higher scores indicating a greater degree of severity of psychological distress. Excellent internal consistency of the K6 was demonstrated in the present sample, α = 0.92. 2.4. Approach to analysis Prior to addressing the study objectives, we calculated means and standard deviations for each of the above variables. With regards to our first objective, we used an independent samples t-test to compare the overall level of pathological narcissism in the sample with that of a sample of 1080 male undergraduates assessed using the full version of the PNI (reported by Wright et al. (2010)). Given the pronounced age difference between these samples, we sought to compare the younger men among our respondents with the undergraduate sample. Hence, we divided our sample into groups of young men (aged 19 – 30; n = 99), middle-age men (aged 31 – 59; n = 615), and older men (aged 60 and older; n = 286) and used t-tests to compare each group with the undergraduate sample. We approached the second objective by first calculating bivariate correlations between pathological narcissism, psychological distress, age, and the four domains of maladaptive self-regulatory behaviours. Next, a series of four hierarchical regression analyses were conducted using each of the maladaptive behaviour domains as the dependent variable. Age, psychological distress (K6 total score), and pathological narcissism (SB-PNI score) were mean-centered and entered simultaneously as predictor variables in the first step. The significance of the SB-PNI regression coefficient would indicate the effect of pathological narcissism while adjusting for age and distress. Two-way interaction terms were created to reflect interactions between pathological narcissism and age (SB-PNI × age) and pathological narcissism and distress (SB-PNI × K6), and entered in the second step of the regression model. The significance of the hierarchical F-test at this level of the analysis would indicate an interaction effect, with the significance of the regression coefficients indicating whether age or distress was a significant moderator of the relationship between pathological narcissism and the maladaptive behaviour in question. Finally, a three-way interaction term (SB-PNI x age x K6) was created and entered in the third step. This interaction would similarly be evaluated based on the significance of change at this level of the analysis (hierarchical F-test). Significance was set at p < 0.01 due to the multiple tests conducted. 3. Results The mean K6 score for respondents was M = 7.51 (SD = 5.38). Scores on the MDRS-22 substance use subscales were M = 0.63 (SD = 1.51) and M = 1.12 (SD = 1.72) for Drug Use and Alcohol Use, respectively. Men's MDRS-22 Anger / Aggression scores were M = 1.39 (SD = 1.68), and Risk-taking scores were M = 0.99 (SD = 1.43). The mean pathological narcissism score is presented in Table 1, along with the results of t-test comparisons of the present sample (both overall and by age groups) with the undergraduate sample reported by Wright et al. (2010). The level of narcissistic tendencies was found to be significantly and substantially lower among the overall current sample when compared to that reported in male college undergraduates. Comparison by age group, however, revealed interesting differences: middle-aged and older men had significantly lower levels of narcissistic tendencies than the undergraduate sample, while the younger men we surveyed indicated a significantly higher level of pathological narcissism. Table 1. Independent samples t-tests comparing levels of pathological narcissism between male undergraduates and the current sample of Canadian men. N M (SD) t (df) Cohen's d Undergraduate sample 1080 2.19 (0.76) – – Current sample, overall 1000 1.69 (1.10) 11.97* (1759.10) 0.53 Current sample, ages 19 – 30 99 2.65 (1.00) −4.46* (108.63) 0.52 Current sample, ages 31 – 59 615 1.78 (1.05) 8.50* (985.11) 0.45 Current sample, ages 60 – 86 286 1.15 (0.95) 17.12* (386.86) 1.21 Notes: Undergraduate sample assessed using full version of the PNI, reported by Wright et al. (2010). Degrees of freedom reflect heterogeneity of variance determined by significant Hartley F-test. * p < 0.001 Table 2 shows the bivariate correlations among the variables in the study. Pathological narcissism was significantly associated with general psychological distress. Both of these variables were positively associated with each of the MDRS-22 maladaptive behaviour domains. A significant inverse relationship was found between age and each of the variables we examined: narcissism, distress, and all maladaptive behaviours. Table 2. Bivariate correlations among pathological narcissism, psychological distress, maladaptive self-regulatory behaviours, and age; N = 1000. 1 2 3 4 5 6 1. Pathological narcissisma 2. Psychological distressb 0.62* 3. Drug Usec 0.36* 0.37* 4. Alcohol Usec 0.39* 0.42* 0.46* 5. Anger / Aggressionc 0.50* 0.59* 0.50* 0.48* 6. Risk-takingc 0.52* 0.55* 0.63* 0.64* 0.68* 7. Age −0.42* −0.34* −0.25* −0.23* −0.26* −0.32* * p < 0.001 a Super Brief Pathological Narcissism Inventory b K6 c Male Depression Risk Scale Pathological narcissism remained significant in the hierarchical regression analysis using drug use as the dependent variable (see Table 3), and the interaction between pathological narcissism and age was significant, though accounting for less than 2% of the variance. In other words, age had a statistically significant though modest effect in moderating the relationship between pathological narcissism and the use of drugs for self-regulatory purposes, indicating that the association between narcissism and drug use was more pronounced for younger men. The three-way interaction between age, distress, and pathological narcissism was non-significant. With regards to alcohol use, pathological narcissism also remained significant alongside psychological distress (see Table 4). No interaction effects were found to be significant when alcohol use was the dependent variable. Table 3. Hierarchical regression analysis of the relationship between pathological narcissism (PN) and drug usea among men, N = 1000. F change R2 B (SE) β t Step 1 69.29** 0.17 Age −0.01 (0.00) −0.10 −2.97* General distress (K6) 0.06 (0.01) 0.23 6.14** Pathological narcissism (SB-PNI) 0.25 (0.05) 0.18 4.76** Step 2 10.96** 0.19 Interaction of PN and age −0.01 (0.00) −0.10 −3.25** Interaction of PN and distress 0.02 (0.01) 0.12 2.01 Step 3 1.22 0.19 Interaction of PN, age, distress 0.00 (0.00) −0.07 −1.10 * p < 0.01 ** p < 0.001 a Dependent variable: drug use (MDRS drug use subscale) Table 4. Hierarchical regression analysis of the relationship between pathological narcissism (PN) and alcohol usea among men, N = 1000. F change R2 B (SE) β t Step 1 87.16** 0.21 Age −0.01 (0.00) −0.05 −1.65 General distress (K6) 0.09 (0.01) 0.28 7.77** Pathological narcissism (SB-PNI) 0.31 (0.06) 0.20 5.35** Step 2 0.03 0.21 Interaction of PN and age 0.00 (0.00) 0.00 −0.13 Interaction of PN and distress 0.00 (0.01) 0.01 0.13 Step 3 0.33 0.21 Interaction of PN, age, distress 0.00 (0.00) 0.04 0.58 *p < 0.01 ** p < 0.001 a Dependent variable: alcohol use (MDRS alcohol use subscale) Pathological narcissism was found to be significantly associated with angry and aggressive behaviour – along with psychological distress – but no interaction effects were found in this analysis (see Table 5). With regards to risk-taking behaviour, a significant interaction between pathological narcissism and distress emerged (see Table 6), though accounting for only 1% of the variance. This suggested that, while pathological narcissism was associated with risk-taking activity, psychological distress had a small though statistically significant moderating effect on this relationship, indicating that the relation between narcissism and risk-taking was more pronounced when distress was high. Table 5. Hierarchical regression analysis of the relationship between pathological narcissism (PN) and angry / aggressive behavioura among men, N = 1000. F change R2 B (SE) β t Step 1 204.65** 0.38 Age 0.00 (0.00) −0.02 −0.75 General distress (K6) 0.14 (0.01) 0.46 14.42** Pathological narcissism (SB-PNI) 0.32 (0.05) 0.21 6.29** Step 2 1.21 0.38 Interaction of PN and age 0.00 (0.00) −0.04 −1.55 Interaction of PN and distress 0.00 (0.01) −0.02 −0.42 Step 3 0.92 0.38 Interaction of PN, age, distress 0.00 (0.00) −0.05 −0.96 *p < 0.01 ** p < 0.001 a Dependent variable: angry / aggressive behaviour (MDRS anger subscale) Table 6. Hierarchical regression analysis of the relationship between pathological narcissism (PN) and risk-taking behavioura among men, N = 1000. F change R2 B (SE) β t Step 1 189.47** 0.36 Age −0.01 (0.00) −0.08 −2.99* General distress (K6) 0.10 (0.01) 0.36 11.26** Pathological narcissism (SB-PNI) 0.34 (0.04) 0.26 7.80** Step 2 7.71** 0.37 Interaction of PN and age −0.01 (0.00) −0.05 −1.91 Interaction of PN and distress 0.02 (0.01) 0.13 2.54* Step 3 0.54 0.37 Interaction of PN, age, distress 0.00 (0.00) 0.04 0.73 * p < 0.01 ** p < 0.001 a Dependent variable: risk-taking behaviour (MDRS risk subscale) 4. Discussion The findings from this study provide evidence for the relationship between narcissistic dysfunction and men's use of unhealthy self-regulatory behaviours. Although general psychological distress accounted for a larger portion of the variance, pathological narcissism nonetheless emerged as being significantly related to several behaviours that often signify externalizing depressive symptoms among men. Narcissistic features were associated with substance overuse, angry and aggressive behaviours, and risk-taking as means to cope with challenging emotional states. This evidence, obtained from a representative cross-section of Canadian based men, lends support to conceptual accounts of a link between the distorted self-image involved in narcissistic pathology and the use of externalizing coping behaviours. Thus, men who act out aggressively or with little concern for safety may be attempting to not only manage a sense of general emotional distress, but also to regulate their narcissistic sensitivity to a lack of admiration. Similarly, men with an inordinately contingent self-concept – tied to the admiring responses of others – may be more inclined to rely on alcohol and drug use as a coping mechanism. Our finding of an association between both alcohol and drug overuse and narcissism is consistent with other studies using undergraduate samples (Luhtanen and Crocker, 2005; MacLaren and Best, 2013; Mowlaie et al., 2016). The overuse of alcohol and drugs may provide an escape from intolerable affects that accompany the experience of a threatened self-image. The small moderating effect of age that emerged in our findings suggests that pathological narcissism may be particularly contributory to drug use as a coping response among younger men. For men with narcissistic features, substance overuse might serve to bypass the emotional distress and psychological work that would otherwise be involved in integrating experiences of disappointment or lack of admiration into a realistic self-representation. At the same time, some men may regard substance overuse itself as a conduit to a positive self-image. We might reasonably speculate that narcissistic features may incline some men toward masculine stereotypes that vaunt substance use as an accessory of being “a real man” (Lemle and Mishkind, 1989). Previous research has indeed linked attitudes toward alcohol use with hegemonic masculine ideals that glorify heavy drinking (Iwamoto et al., 2011; Peralta, 2007). Risk-taking behaviours may similarly be viewed by some men as a means of self enhancement. When faced with experiences of diminished self-worth, men with narcissistic tendencies may regard themselves with greater potency by conducting themselves with a sense of abandon. Reckless behaviours may also bring a rush of exhilaration that, like substance use, counteracts negative affect. Indeed, our findings suggest that the relationship between pathological narcissism and risk-taking activity seems to be somewhat stronger in the context of greater psychological distress. One could also speculate that by acting without concern for consequences, a distressed man may be expressing in a rather dramatic way that he does not care about what others think – a behavioural denial of a fragile self-image. Aggression has been theorized as a means by which a threatened self-image may be regulated and compensated for (Kohut, 1972). While our study did not examine the role of threatened self-image, we speculate that the association found between aggressive behaviour and pathological narcissism could possibly be explained by such phenomena. It may be that men with higher levels of narcissistic dysfunction engage in aggressive behaviour in order to avert feelings of insecurity. Recent research has implicated narcissistic vulnerability in fueling reactive anger – even in response to fairly minor provocations (Krizan and Johar, 2015). One could also speculate that hegemonic masculine ideals may also infiltrate the relationship between pathological narcissism and aggression among men. Indeed, masculine identity norms have been linked to endorsement and / or embodiment of aggression (Cohn and Zeichner, 2006). Ideals equating masculinity with power, control, and aggression could possibly be regarded as particularly salient among men whose self-representations are relatively less nuanced and contingent upon external validation. The age difference in levels of narcissistic features among respondents is worth noting. Although the level of pathological narcissism across the entire sample was found to be lower than that in undergraduate samples, there were significant differences between younger men and those in the middle-age and older groups. Indeed, the young men in our sample endorsed a greater degree of narcissistic dysfunction than that reported by undergraduates, though the use of different versions of the PNI warrants caution in interpreting this finding. Of particular concern is the issue of younger men in our sample having a slightly higher risk of drug abuse associated with pathological narcissism. With regards to age differences, Stinson and colleagues (2008) also found markedly higher levels of narcissism among younger adults compared to older adults. Some authors have suggested that modern culture fosters narcissism, and that such tendencies are on the rise in younger generations (Twenge and Campbell, 2009). However, a number of factors – methodological issues (Trzesniewski and Donnellan, 2010), complex cultural shifts (Gabbard and Crisp‐Han, 2016), and the possibility of longitudinal changes in narcissism (Roberts et al., 2010) – provide reason to question this conclusion. Overall, our findings suggest a relative paucity of constructive self-regulatory options for men with high levels of pathological narcissism. Further research is needed to tease apart the mechanisms underlying these relationships. Future studies, for example, could focus on masculinities (Robertson et al., 2016) and examine the degree to which a plurality of alignments to hegemonic masculine ideals may be entwined with narcissistic personality features in contributing to men's health outcomes. As well, studies that include additional intermediary variables such as affective and interpersonal experiences, emotional processing, and self-control should be undertaken with measurement at different time points, in order to understand the pathways between narcissistic pathology and potentially risky self-regulatory behaviours. Indeed, our use of a cross-sectional, survey methodology limits the inferences that can be drawn from the present study, and increases the risk of shared-method variance. A further limitation involves our use of a single, brief self-report measure of pathological narcissism. Assessment difficulties have plagued the narcissism research literature, with social psychologists and clinical researchers espousing diverse perspectives regarding optimal measurement (Brown and Tamborski, 2011; Cain et al., 2008; Miller et al., 2014). The PNI has been critiqued as capturing more of a vulnerable form of narcissism that diverges from DSM criteria for NPD (Miller et al., 2014). While this may limit the degree to which our findings speak to a relatively “pure” form of grandiose narcissism, we do not regard this as inherently problematic, given the substantial emphasis on narcissistic vulnerability in the clinical literature (Caligor et al., 2015; Levy, 2012; Pincus et al., 2015). Although our survey format necessitated a brief measure, assessment of pathological narcissism should ideally use more than one type of measurement – including interview-based and self-report methods. Refined assessment methods would help to clarify the differential roles of grandiosity, vulnerability, and other subcomponents of pathological narcissism – especially if combined with approaches such as ecological momentary assessment that capture fluctuations in narcissistic functioning over time. Another next step would be to examine pathological narcissism and risk-taking behaviours among women. Notwithstanding the above limitations, the findings from this national Canadian survey point to potential clinical and public health implications. First, clinicians working with men who present with problematic substance use or aggressive behaviour may need to be sensitized to the potential presence of narcissistic dysfunction. Not all clinically significant narcissism is manifest in overt grandiosity (Caligor et al., 2015; Kealy and Rasmussen, 2012). Clinicians may thus need to attend to subtle clues regarding features of narcissistic vulnerability that may contribute to the presenting problem behaviour[s]. Awareness of narcissistic dysfunction can inform clinicians’ interventions (Kealy et al., 2015; Pincus et al., 2014), and mitigate potential alliance difficulties with men whose contingent self-image may be threatened by aspects of the clinical encounter (Ronningstam, 2012). Public health promotion may also need to address narcissism among men – particularly young men. Indeed, narcissistic personality disorder is one of the most stigmatized mental health conditions, given the apparent social permissiveness with which the term “narcissist” is used pejoratively. Our findings, along with those of other researchers (e.g., Ansell et al., 2015; Miller et al., 2007), indicate that narcissistic issues ought not be taken lightly. After all, substance abuse, aggression, and recklessness pose considerable health and safety risks. Hopefully, recognition of the maladaptive behaviours associated with pathological narcissism can shape broader public discourse in order that men can speak more openly about challenges related to self-image and self-regulatory difficulties. Acknowledgement Thanks to Intensions Consulting (http://www.intensions.co/) for assisting with data collection and analysis. References Ansell et al., 2015 E.B. Ansell, A.G.C. Wright, J.C. Markowitz, C.A. Sanislow, C.J. Hopwood, M.C. Zanarini, S. Yen, A. Pinto, T.H. McGlashan, C.M. Grilo Personality disorder risk factors for suicide attempts over 10 years of follow-up Pers. Disord., 6 (2015), pp. 161-167 CrossRefView Record in Scopus Archer, 2004 J. Archer Sex differences in aggression in real-world settings: a meta-analytic review Rev. Gen. Psychol., 8 (2004), pp. 291-322 CrossRefView Record in Scopus Blasco-Fontecilla et al., 2009 H. Blasco-Fontecilla, E. Baca-Garcia, K. Dervic, M.M. Perez-Rodriguez, J. Lopez-Castroman, J. Saiz-Ruiz, M.A. Oquendo Specific features of suicidal behavior in patients with narcissistic personality disorder J. Clin. Psychiatry, 70 (2009), pp. 1583-1587 CrossRefView Record in Scopus Brady and Randall, 1999 K.T. Brady, C.L. Randall Gender differences in substance use disorders Psychiatr. Clin. North. Am., 22 (1999), pp. 241-252 ArticleDownload PDFView Record in Scopus Brown and Tamborski, 2011 R.P. Brown, M. Tamborski Of tails and their dogs: a critical view of the measurement of trait narcissism in social-personality research W.K. Campbell, J.D. Miller (Eds.), The Handbook of Narcissism and Narcissistic Personality Disorder, John Wiley and Sons, Hoboken, NJ (2011), pp. 141-145 CrossRefView Record in Scopus Buelow and Brunell, 2014 M.T. Buelow, A.B. Brunell Facets of grandiose narcissism predict involvement in health-risk behaviors Pers. Indiv. Differ., 69 (2014), pp. 193-198 ArticleDownload PDFView Record in Scopus Bushman and Baumeister, 1998 B.J. Bushman, R.F. Baumeister Threatened egotism, narcissism, self-esteem, and direct and displaced aggression: does self-love or self-hate lead to violence? J. Pers. Soc. Psychol., 75 (1998), pp. 219-229 CrossRefView Record in Scopus Caligor et al., 2015 E. Caligor, K.N. Levy, F.E. Yeomans Narcissistic personality disorder: diagnostic and clinical challenges Am. J. Psychiatry, 172 (2015), pp. 415-422 CrossRefView Record in Scopus Cohn and Zeichner, 2006 A. Cohn, A. Zeichner Effects of masculine identity and gender role stress on aggression in men Psychol. Men. Masc., 4 (2006), pp. 179-190 CrossRefView Record in Scopus Cooper, 2009 A.M. Cooper The narcissistic-masochistic character Psychiatr. Ann., 39 (2009), pp. 904-912 CrossRefView Record in Scopus Cramer, 2017 P. Cramer Identity change between late adolescence and adulthood Pers. Individ. Differ., 104 (2017), pp. 538-543 ArticleDownload PDFView Record in Scopus Dowgwillo et al., 2016 E.A. Dowgwillo, S. Dawood, A.L. Pincus The dark side of narcissism V. Zeigler-Hill, D.K. Markus (Eds.), The Dark Side of Personality: Science and Practice in Social, Personality, and Clinical Psychology, American Psychological Association, Washington (2016), pp. 25-44 CrossRefView Record in Scopus Edwards et al., 2013 B.D. Edwards, C.R. Warren, T.C. Tubré, M.J. Zyphur, R. Hoffner-Prillaman The validity of narcissism and driving anger in predicting aggressive driving in a sample of young drivers Hum. Perform., 26 (2013), pp. 191-210 CrossRefView Record in Scopus Ellison et al., 2013 W.D. Ellison, K.N. Levy, N.M. Cain, E.B. Ansell, A.L. Pincus The impact of pathological narcissism on psychotherapy utilization, initial symptom severity, and early-treatment symptom change: a naturalistic investigation J. Pers. Assess., 95 (2013), pp. 291-300 CrossRefView Record in Scopus Fossati et al., 2010 A. Fossati, S. Borroni, N. Eisenberg, C. Maffei Relations of proactive and reactive dimensions of aggression to overt and covert narcissism in nonclinical adolescents Aggress. Behav., 36 (2010), pp. 21-27 CrossRefView Record in Scopus Foster et al., 2009 J.D. Foster, J.W. Shenesey, J.S. Goff Why do narcissists take more risks? Testing the roles of perceived risks and benefits of risky behaviors Pers. Individ. Differ., 47 (2009), pp. 885-889 ArticleDownload PDFView Record in Scopus Gabbard and Crisp‐Han, 2016 G.O. Gabbard, H. Crisp‐Han The many faces of narcissism World Psychiatry, 15 (2016), pp. 115-116 CrossRefView Record in Scopus Goldberg et al., 2007 B.R. Goldberg, M.R. Serper, M. Sheets, D. Beech, C. Dill, K.G. Duffy Predictors of aggression on the psychiatric inpatient service: self-esteem, narcissism, and theory of mind deficits J. Nerv. Ment. Dis., 195 (2007), pp. 436-442 View Record in Scopus Gore and Widiger, 2016 W.L. Gore, T.A. Widiger Fluctuation between grandiose and vulnerable narcissism Pers. Disord., 7 (2016), pp. 363-371 CrossRefView Record in Scopus Grosch, 1994 W.N. Grosch Narcissism: shame, rage and addiction Psychiatr. Quart., 65 (1994), pp. 49-63 CrossRefView Record in Scopus Hill, 2015 E.M. Hill The role of narcissism in health-risk and health-protective behaviors J. Health Psychol. (2015), 10.1177/1359105315569858 Iwamoto et al., 2011 D.K. Iwamoto, A. Cheng, C.S. Lee, S. Takamatsu, D. Gordon “Man-ing” up and getting drunk: the role of masculine norms, alcohol intoxication and alcohol-related problems among college men Addict. Behav., 36 (2011), pp. 906-911 ArticleDownload PDFView Record in Scopus Kealy et al., 2015 D. Kealy, G. Goodman, B. Rasmussen, R. Weideman, J.S. Ogrodniczuk Therapists' perspectives on optimal treatment for pathological narcissism Pers. Disord. (2015), 10.1037/per0000164 Kealy and Rasmussen, 2012 D. Kealy, B. Rasmussen Veiled and vulnerable: the other side of grandiose narcissism Clin. Soc. Work. J., 40 (2012), pp. 356-365 CrossRefView Record in Scopus Kealy et al., 2012 D. Kealy, M. Tsai, J.S. Ogrodniczuk Depressive tendencies and pathological narcissism among psychiatric outpatients Psychiatr. Res., 196 (2012), pp. 157-159 ArticleDownload PDFView Record in Scopus Kernberg, 1984 O.F. Kernberg Severe Personality Disorders: Psychotherapeutic Strategies Yale University Press, New Haven (1984) Kernberg, 2014 O.F. Kernberg An overview of the treatment of severe narcissistic pathology Int. J. Psychoanal., 95 (2014), pp. 865-888 CrossRef Kessler et al., 2002 R.C. Kessler, G. Andrews, L.J. Colpe, E. Hiripi, D.K. Mroczek, S.L. Normand, E.E. Walters, A.M. Zaslavsky Short screening scales to monitor population prevalences and trends in non-specific psychological distress Psychol. Med., 32 (2002), pp. 959-976 CrossRefView Record in Scopus Kohut, 1972 H. Kohut Thoughts on narcissism and narcissistic rage Psychoanal. Study Child., 27 (1972), pp. 360-400 CrossRefView Record in Scopus Kohut and Wolf, 1978 H. Kohut, E.S. Wolf The disorders of the self and their treatment: an outline Int. J. Psychoanal., 59 (1978), pp. 413-425 View Record in Scopus Krizan and Johar, 2015 Z. Krizan, O. Johar Narcissistic rage revisited J. Pers. Soc. Psychol., 108 (2015), pp. 784-801 CrossRefView Record in Scopus Larson et al., 2015 M. Larson, M.G. Vaughn, C.P. Salas-Wright, M. Delisi Narcissism, low self-control, and violence among a nationally representative sample Crim. Justice Behav., 42 (2015), pp. 644-661 CrossRefView Record in Scopus Lemle and Mishkind, 1989 R. Lemle, M.E. Mishkind Alcohol and masculinity J. Subst. Abus. Treat., 6 (1989), pp. 213-222 ArticleDownload PDFView Record in Scopus Levy, 2012 K.N. Levy Subtypes, dimensions, levels, and mental states in narcissism and narcissistic personality disorder J. Clin. Psychol., 68 (2012), pp. 886-897 CrossRefView Record in Scopus Lobbestael et al., 2014 J. Lobbestael, R.F. Baumeister, T. Fiebig, L.A. Eckel The role of grandiose and vulnerable narcissism in self-reported and laboratory aggression and testosterone reactivity Pers. Individ. Differ., 69 (2014), pp. 22-27 ArticleDownload PDFView Record in Scopus Luhtanen and Crocker, 2005 R.K. Luhtanen, J. Crocker Alcohol use in college students: effects of level of self-esteem, narcissism, and contingencies of self-worth Psychol. Addict. Behav., 19 (2005), pp. 99-103 CrossRefView Record in Scopus MacLaren and Best, 2013 V.V. MacLaren, L.A. Best Disagreeable narcissism mediates an effect of BAS on addictive behaviors Pers. Individ. Differ., 55 (2013), pp. 101-105 ArticleDownload PDFView Record in Scopus Miller et al., 2007 J.D. Miller, W.K. Campbell, P.A. Pilkonis Narcissistic personality disorder: relations with distress and functional impairment Compr. Psychiatry., 48 (2007), pp. 170-177 ArticleDownload PDFView Record in Scopus Miller et al., 2014 J.D. Miller, J. McCain, D.R. Lynam, L.R. Few, B. Gentile, J. MacKillop, W.K. Campbell A comparison of the criterion validity of popular measures of narcissism and narcissistic personality disorder via the use of expert ratings Psychol. Assess., 26 (2014), pp. 958-969 CrossRefView Record in Scopus Mowlaie et al., 2016 M. Mowlaie, A. Abolghasemi, N. Aghababaei Pathological narcissism, brain behavioral systems and tendency to substance abuse: the mediating role of self-control Pers. Individ. Differ., 88 (2016), pp. 247-250 ArticleDownload PDFView Record in Scopus Ogrodniczuk, 2013 J.S. Ogrodniczuk Understanding and Treating Pathological Narcissism American Psychological Association, Washington (2013) Ogrodniczuk et al., 2009 J.S. Ogrodniczuk, W.E. Piper, A.S. Joyce, P.I. Steinberg, S. Duggal Interpersonal problems associated with narcissism among psychiatric outpatients J. Psychiatr. Res., 43 (2009), pp. 837-842 ArticleDownload PDFView Record in Scopus Peralta, 2007 R.L. Peralta College alcohol use and the embodiment of hegemonic masculinity among European American men Sex. Roles, 56 (2007), pp. 741-756 CrossRefView Record in Scopus Pincus, 2013 A.L. Pincus The pathological narcissism inventory J.S. Ogrodniczuk (Ed.), Understanding and Treating Pathological Narcissism, American Psychological Association, Washington (2013), pp. 93-110 CrossRefView Record in Scopus Pincus et al., 2009 A.L. Pincus, E.B. Ansell, C.A. Pimentel, N.M. Cain, A.G. Wright, K.N. Levy Initial construction and validation of the Pathological Narcissism Inventory Psychol. Assess., 21 (2009), pp. 365-379 CrossRefView Record in Scopus Pincus et al., 2014 A.L. Pincus, N.M. Cain, A.G.C. Wright Narcissistic grandiosity and narcissistic vulnerability in psychotherapy Pers. Disord., 5 (2014), pp. 439-443 CrossRefView Record in Scopus Pincus and Lukowitsky, 2010 A.L. Pincus, M.R. Lukowitsky Pathological narcissism and narcissistic personality disorder Ann. Rev. Clin. Psychol., 6 (2010), pp. 421-446 CrossRefView Record in Scopus Pincus et al., 2015 A.L. Pincus, M.J. Roche, E.W. Good Narcissistic personality disorder and pathological narcissism P.H. Blaney, R.F. Krueger, T. Millon (Eds.), Oxford Textbook of Psychopathology (3rd ed.), Oxford University Press, New York (2015), pp. 791-813 View Record in Scopus Rice et al., 2013 S.M. Rice, B.J. Fallon, H.M. Aucote, A.M. Möller-Leimkühler Development and preliminary validation of the male depression risk scale: furthering the assessment of depression in men J. Affect. Disord., 151 (2013), pp. 950-958 ArticleDownload PDFView Record in Scopus Roberts et al., 2010 B.W. Roberts, G. Edmonds, E. Grijalva It is developmental me, not Generation Me: developmental changes are more important than generational changes in Narcissism – Commentary on Trzesniewski and Donnellan (2010) Perspect. Psychol. Sci., 5 (2010), pp. 97-102 CrossRefView Record in Scopus Robertson et al., 2016 S. Robertson, B. Williams, J. Oliffe The case for retaining a focus on “masculinities” in men's health research Int. J. Mens Health (2016), p. 15 〈http://www.mensstudies.info/OJS/index.php/IJMH/article/view/750〉 View Record in Scopus Ronningstam, 2011 E. Ronningstam Narcissistic personality disorder: a clinical perspective J. Psychiatr. Pract., 17 (2011), pp. 89-99 CrossRefView Record in Scopus Ronningstam, 2005 E.F. Ronningstam Identifying and Understanding the Narcissistic Personality Oxford University Press, New York (2005) Ronningstam, 2012 E.F. Ronningstam Alliance building and narcissistic personality disorder J. Clin. Psychol., 68 (2012), pp. 943-953 CrossRefView Record in Scopus Schoenleber et al., 2015 M. Schoenleber, M.J. Roche, E. Wetzel, A.L. Pincus, B.W. Roberts Development of a brief version of the Pathological Narcissism Inventory Psychol. Assess., 27 (2015), pp. 1520-1526 CrossRefView Record in Scopus Stinson et al., 2008 F.S. Stinson, D.A. Dawson, R.B. Goldstein, S.P. Chou, B. Huang, S.M. Smith, W.J. Ruan, A.J. Pulay, T.D. Saha, R.P. Pickering, B.F. Grant Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions J. Clin. Psychiatry, 69 (2008), pp. 1033-1045 CrossRefView Record in Scopus Trzesniewski and Donnellan, 2010 K.H. Trzesniewski, M.B. Donnellan Rethinking “Generation Me” a study of cohort effects from 1976–2006 Perspect. Psychol. Sci., 5 (2010), pp. 58-75 CrossRefView Record in Scopus Twenge and Campbell, 2009 J.M. Twenge, W.K. Campbell The Narcissism Epidemic: Living in the Age of Entitlement Simon and Schuster, New York (2009) Wright et al., 2010 A.G. Wright, M.R. Lukowitsky, A.L. Pincus, D.E. Conroy The higher order factor structure and gender invariance of the Pathological Narcissism Inventory Assessment, 17 (2010), pp. 467-483 CrossRefView Record in Scopus © 2017 Elsevier B.V. All rights reserved.