In effect, narcissism refers to a very fragile and unstable sense of self. In order to compensate for their fragile self-esteem, narcissistic people become preoccupied with their self-image and intensely sensitive to perceived shame or humiliation. Typical narcissists have a grandiose sense of self, with an inflated sense of self-importance and an elevated need for attention, status, and recognition. More recent research has focused upon a kind of reverse narcissism, in which people are tormented by poor self-esteem, but harbor grandiose expectations of themselves. The Diagnostic and Statistical Manual, fourth edition (DSM-IV or DSM-IV-TR) lists nine criteria for the diagnosis of narcissistic personality disorder.